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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 neuro physiological models of emotion regulation in general and examine how those models, both neuro physiologically and neuro anatomically, are expressed in individuals with BPD. We examine how neuro imaging, both anatomical and functional, reveals the roles that various neuro anatomical structures play in the regulation of emotion in BPD. We conclude by creating a neuro development al model that describes how a complex matrix involving the interplay of constitutional 0 biological predispositions with environmental stress ors 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.
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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. PUTNAMa,b and KENNETH R. SILKc
aNational Center for PTSD, Boston; bBoston University Medical Center; and
cUniversity 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
scribes deficiencies in emotion regulation
either good or bad, but thinking makes it so: to me
~along with a nonvalidating early environ-
it is a prison.
ment and low distress tolerance with the sub-
Act 2, Scene 2, Hamlet, William Shakespeare
sequent development of poor coping skills! as
setting the stage for the development of bor-
That dysregulation of emotion is a core fea-
derline symptoms, especially, but not exclu-
ture of borderline personality disorder ~BPD!
sively, with respect to the clinical presentation
appears to be a given. In a three-part review
of parasuicidal behavior ~Linehan, 1987, 1993!.
of BPD in 2002, the third and final part put
In Zanarini, Frankenburg, Hennen, and Silk’s
forth the idea that emotional lability or emo-
~2003! 6-year follow-along study of BPD, 90%
tion dysregulation was one of the two major
of the BPD group endorsed affective instabil-
endophenotypes of BPD ~Siever, Torgersen,
ity at baseline, in contrast to endorsement by
Gunderson, Livesley, & Kendler, 2002!, the
30.6% of the comparison cohort with other
other being impulsive aggression. This idea of
personality disorders. Fifty percent of the BPD
dysregulation of emotions as a prime driver or
group continued to endorse this symptom af-
underlying constitutional predisposition for
ter 6 years. Sanislow, Grilo, Morey, Bender,
some of the symptoms found in BPD has been
Skodol, and Gunderson ~2002!, working in
presented by others as well. Linehan de-
the Collaborative Longitudinal Personality Dis-
orders Study, found, by employing factor analy-
sis, that three factors emerged in BPD ~although
Address correspondence and reprint requests to: Kenneth
the results can also be interpreted as represent-
R. Silk, University of Michigan Health System, 1500
ing a single factor for the disorder!: disturbed
East Medical Center Drive, MCHC-6, Box 0295, Ann
Arbor, MI 48109-0295; E-mail: ksilk@umich.edu.
relatedness, behavioral dysregulation ~impul-
899

900
K. M. Putnam and K. R. Silk
sivity!, and affective dysregulation. Koenigs-
systems ~Depue & Lenzenweger, 2001, 2005!,
berg et al. ~2002! explored the clinical nature
for our purposes here we will consider emo-
of affective instability in 42 patients with BPD
tion regulation as a somewhat separate sys-
and found, when comparing them to 110 pa-
tem. We “isolate” this system to review what
tients with other personality disorders, that
is known about this aspect of behavior and to
patients with BPD showed greater lability be-
look at how this aspect of behavior, particu-
tween the states of anger and anxiety, depres-
larly when it is pathological in its regulation,
sion and anxiety, and within the various
may play a developmental role in BPD.
clinical manifestations of anxiety. However,
There are many researchers who do isolate
the BPD cohort did not reveal greater lability
the emotional regulation system and consider
between depression and elation. Nonetheless,
its dysfunction as a core component of BPD
on subjective ratings, the BPD subjects did
~Corrigan, Davidson, & Heard, 2000; Her-
not experience greater intensity of affects than
pertz, Kunert, Schwenger, & Sass, 1999; Line-
did the comparison group. In the classic arti-
han, 1993; Silk, 2000; Stiglmayr, Shapiro,
cle by Siever and Davis on the biology of
Stieglitz, Limberger, & Bohus, 2001!. The in-
personality disorders ~Siever & Davis, 1991!,
ability to sustain positive affect coupled with
affective instability is listed as one of the four
the pervasive and unremitting distress as ex-
dimensions of psychopathology that can be
perienced by patients with BPD can become a
viewed as cutting across, from a biological
veritable prison to those with the disorder and
point of view, a number of personality disor-
often as well to those who attempt to treat or
ders. Siever and Davis point out that affective
help an individual with BPD. However, the
instability is very closely related to BPD ~and
nature of this particular dysfunction in BPD
perhaps histrionic personality disorder as well!,
remains a curious phenomenon because indi-
and they suggest that defects in the choliner-
viduals with BPD are quite able in a number
gic and adrenergic systems may be important
of instances to utilize emotion regulatory mech-
underlying neuroregulatory mechanisms that
anisms effectively. Specifically, individuals
play a key role in the development of this
with BPD can proficiently intensify the va-
affective instability.
lence and arousal of negative stimuli as well
Although Siever and Davis’s ~1991! work
as prolong the duration of the effect of the
was very important in pointing out that there
stimulus. In addition, they are able to suppress
may be significant biological underpinnings
the intensity, valence, and duration of a poten-
to many of the personality disorders, their
tially positive stimulus. Thus, they demon-
initial hypothesis appears today to lack pre-
strate an operative, albeit baneful, capacity to
cision. More recent work by Depue and Len-
alter the emotional tenor of a stimulus. How-
zenweger ~2001, 2005! suggests that the
ever, over the long run, these strategies are
neurobehavioral and neurobiological systems
short acting, inconsistent with the goals of the
that underlie many of the dimensions of be-
individual, and disruptive to effective interper-
havior ~and psychopathology! are the result of
sonal functioning, most probably because pa-
complex interactions of multiple systems. It is
tients with BPD have a greater tendency to
this interaction among neurotransmitters ~and
experience emotions with negative valence than
the underlying behavioral systems!, and no
to experience and recall emotions of neutral
single neurotransmitter, that leads to the dif-
and or positive valence ~Donegan et al., 2003;
fering phenotypic presentations of behavior
Korfine & Hooley, 2000; Kurtz & Morey,
among patients with personality disorders
1998!. Consequently, although patients with
~Depue & Lenzenweger, 2001, 2005!.
BPD do reveal the ability to regulate or change
Although some may argue that the idea of
their emotions, the particular ways in which
considering specific symptoms of BPD is in-
they frequently utilize these coping mecha-
herently open to criticism because all symp-
nisms are not consistent with some accepted
toms found in BPD and other personality
definitions of emotion regulation.
disorders are really just differing expressions
In reviewing the concept of emotion regu-
of interactions of consistent neurobehavioral
lation in BPD, we will not cover the broader

Emotion dysregulation and the development of BPD
901
definition of emotion regulation, but we will
cept. Of course, at this time, BPD was not
try to focus on those aspects of emotion regu-
even considered a legitimate diagnostic entity.
lation that lead to what we identify as symp-
When Gunderson and Singer ~1975! sug-
toms within the criteria set of BPD. Thus,
gested a set of six criteria that they gleaned
taking BPD as our focus, this paper will ex-
from a review of the literature of the various
plore various definitions and understandings
“definitions” of borderline over the years be
of emotion dysregulation, its cognitive as-
included in a diagnostic entity called BPD,
pects, its possible development and role within
the idea of affective and interpersonal fluctu-
the familial ~broadly speaking! context, as well
ations of mood and behavior began to be seen
as some of the more recent neuroimaging work
as one of the central concepts underlying the
that may shed some light on this particular
diagnosis. However, it was not until 1980 and
aspect of BPD. It will also propose a nascent
the publication of the DSM-III that BPD
theory of the role of emotion regulation, par-
achieved the status of being an official diag-
ticularly as it develops during childhood, in
nosis ~American Psychiatric Association,
the development of BPD.
1980!. Affective instability as defined by
“marked shifts from normal mood to depres-
sion, irritability, or anxiety, usually lasting a
The BPD Diagnosis and Emotion
few hours and only rarely more than a few
Dysregulation as a Symptom of BPD
days, with a return to normal mood” ~Ameri-
can Psychiatric Association, 1980, p. 323! was
The types of patients that were classified as
listed as one of the eight criteria in the DSM-III
falling into the borderline category initially
definition of BPD. That specific criterion has
were not considered to have a disorder related
withstood changes in DSM-III-R as well as in
to mood instability or affective dyscontrol.
DSM-IV, and it currently appears as “affec-
Early descriptions of patients who were la-
tive instability due to a marked reactivity of
beled borderline focused primarily on dis-
mood ~e.g., intense episodic dysphoria, irrita-
turbed, even if they were transient, cognitive
bility, or anxiety usually lasting a few hours
processes ~ Deutsch, 1943; Frosch, 1964;
and only rarely more than a few days!” ~Amer-
Knight, 1953; Zilboorg, 1941!, and many of
ican Psychiatric Association, 2000, p. 710! in
those who were then called borderline were
DSM-IV-TR. Other DSM-IV BPD criteria that
later to be viewed as fitting more appropri-
also fall under a broad definition of affective
ately into what we currently call schizotypal
instability or emotion dysregulation or that
personality disorder ~Spitzer, Endicott, & Gib-
may be considered a byproduct of an inabil-
bon, 1979!. Although there certainly were
ity to control or master affective responses
mood changes associated with these cognitive
and the behavior attached to them could in-
fluctuations that included transient psychotic
clude six of the nine DSM-IV-TR BPD crite-
episodes, these patients were primarily de-
ria. In addition to affective instability, frantic
scribed as falling somewhere within the schizo-
efforts to avoid real or imagined abandon-
phrenic, or at least the psychotic, spectrum
ment, unstable, and intense interpersonal re-
~Deutsch, 1943; Hoch & Polatin, 1949; Knight
lationships, identity disturbance, impulsivity,
1953; Stern, 1938!. It was 1947 when Schmide-
recurrent suicidal behaviors, or gestures or
berg ~1947! first suggested that a disturbed
threats, and inappropriate and intense anger
regulation in affect might be a major aspect of
or inability in controlling one’s anger could
these “borderline” patients. She proposed that
all be seen as relating in some way to an
these patients had an emotional instability that
inability to regulate affect and the behavioral
was essentially a stable aspect of their person-
expression of that affect.
ality functioning, but at least 20 years were to
The emotional instability criterion as part
pass before the emotional lability, instability,
of BPD has not been extensively studied, but
or dysregulation aspect of these patients’ clin-
is considered by many to be a hallmark of the
ical presentation and behavior was to take hold
BPD diagnosis. It is thought to be ~especially
as a central idea within the borderline con-
if one considers anger to be representative of

902
K. M. Putnam and K. R. Silk
emotional or affective lability! a prime insti-
intensive and temporal features, to accom-
gator of transference–countertransference is-
plish one’s goals” ~Thompson, 1994, pp. 27–
sues in patients with BPD ~Gunderson, 1984;
28!. If we accept this functionalistic definition,
Gabbard & Wilkinson, 1994! and, as sug-
we are allowing that individuals with BPD do
gested above, it can be viewed as contributing
indeed demonstrate quite effective emotion reg-
to the impulsivity, anger, interpersonal rela-
ulation skills. For instance, if one’s goal is to
tionship dysfunction, self-image, and parasui-
alleviate a state of numbness and emptiness,
cidal behavior found in some people with BPD.
creating physical pain by cutting or burning
oneself is certainly an efficient technique.
Although many theorists emphasize the dis-
Definition of Emotion Regulation
organizing and stressful aspects of emotion,
Thompson’s model additionally accentuates the
Two-factor models
perspective that emotion has adaptive and syn-
Although emotion dysregulation is clearly a
thesizing qualities. Other writers underscore
symptom and may be behind a number of
this as well ~see Barrett & Campos, 1987;
symptoms in the clinical presentation of BPD,
Malatesta, 1990!. In Thompson’s view, emo-
the mechanism of this disruption remains un-
tion can both enhance or undermine effective
defined because the delineation of the concept
functioning, and he views emotion regulation
of emotion regulation is not clearly agreed
processes to be important “as they enlist emo-
upon. Thus, the particular disruption or set of
tion to support adaptive, organized behav-
disruptions remains unclear from a physiolog-
ioral strategies” ~Thompson, 1994, p. 25!.
ical and psychological perspective. In gen-
Thompson’s view of emotion regulation is pri-
eral, the process of emotion regulation is
marily a functional view because he depicts
viewed as providing individuals with the equip-
the role of effective emotion regulation as al-
ment to respond flexibly to the demands of
lowing emotional responses to be “flexible
their environment ~Campos, Campos, &
~rather than stereotypical!, situationally respon-
Barrett, 1989; Cole, Michel, & Teti, 1994;
sive ~rather than rigid!, and performance en-
Thompson, 1994!. However, responding to the
hancing ~rather than over- or underarousing!,
demands of the environment may really be
and must change quickly and effectively to
only one side of the coin, because the regula-
adapt to changing conditions if they are to
tion of emotion can be conceptualized as hav-
support organized, constructive functioning in
ing both adaptive and maladaptive aspects.
higher organisms” ~Thompson, 1994, p. 26!.
There are other controversial issues that sur-
Thompson’s ~1994! description of the de-
round the concept of emotion dysregulation.
velopment of emotion regulation emphasizes
Two primary issues are ~a! whether emotion
the role of multiple pathways that consist of
and emotion regulation occur in a sequential
external agents that are in place to manage the
manner, with the functional goal of the regu-
emotions of children as well as the child’s
lation to alter somehow the emotional re-
own developing capacity to self-regulate. What
sponse to the experienced emotion, that is,
becomes critical to the development of emo-
whether the emotion and the response to the
tion regulation in Thompson’s view is the
emotion are linked, or whether these two en-
emerging of the child more and more into a
tities are each singly determined; and ~b!
social context. Caregivers help the child man-
whether these processes are under the control
age emotional experience by a number of dif-
of the individual or operate in a more auto-
ferent mechanisms including direct intervention
matic and involuntary manner.
to relieve distress ~Gekoski, Rovee–Collier,
In a review of the processes and mecha-
& Carulli–Rabinowitz, 1983; Lamb & Malkin,
nisms implicated in emotion regulation,
1986!; modeling and selective reinforcement
Thompson ~1994! defined emotion regulation
of positive emotion expression ~Malatesta–
as “the extrinsic and intrinsic processes re-
Magai, 1991!; induction as well as modifica-
sponsible for monitoring, evaluating, and mod-
tion of emotion through affective contagion,
ifying emotional reactions, especially their
empathy, and social referencing ~Thompson,

Emotion dysregulation and the development of BPD
903
Table 1. Thompson’s processes involved in the development of emotion regulation
Types of Processes
Description
Neurophysiological constituents
Systems of nervous system organization that have evolved
to regulate arousal ~including emotional arousal! through
the interplay of excitatory and inhibitory mechanisms
Attention processes
Manage the intake of emotionally arousing information by
removing or refocusing attention
Construals of emotionally arousing
Altering interpretations or construals of emotional
events
information in order lessen negative affect
Encoding of internal emotion cues
Reinterpreting the internal ~i.e., conscious physiology!
indicators of emotional arousal
Access to coping resources
Enhancing one’s access to coping resources, both material
and interpersonal
Regulating the emotional demands of
Predicting and controlling the emotional requirements of
familiar settings
commonly encountered settings and situations
Selecting adaptive response alternatives
Expressing emotion in a manner that is concordant with
one’s personal goals for the situation
Note: Adapted from Thompson ~1994!.
1987!; verbal instruction about emotion and
involved here are voluntary. For example, he
emotion regulation strategies ~Dunn & Brown,
writes that “attention processes” are the first
1991; Miller & Sperry, 1987!; and the control
regulatory mechanisms observed, and an ex-
of opportunities for emotional arousal through
ample of its simplest form is the redirection of
environmental organization. It is clear that the
gaze. Less consideration is given to automatic
central role of the caretaker in the modeling
regulatory processes of attention, for exam-
and initiation of emotion regulation capacity
ple, that lead to disregarding task-irrelevant
can result in a variety of potential mishaps,
emotional stimuli. “Construals” or “interpre-
some certainly more damaging than others.
tations” arrive at later stages of development
However, by ascribing the environmental facet
and are learned cognitive techniques that we
of emotion dysregulation to a narrow and spe-
can observe to develop efficacy over time.
cific feature, such as trauma or emotional in-
Another cognitive strategy is “encoding of in-
validation, ~which is often done in some
ternal emotion cues” where one reframes what
theories of BPD!, we may be losing both the
one is experiencing physiologically. The last
complexity of as well as the subtleties in-
three processes in Table 1 implicate some de-
volved in the evolution of the dysfunction.
gree of environmental control that may or may
Thompson ~1994! describes seven pro-
not be available. However, the first box in
cesses0mechanisms implicated in the develop-
Table 1, described as “neurophysiological
ment of emotion regulation in children ~see
constituents,” may not fall into Thompson’s
Table 1!.
two phenomena or two-factor categorization.
Thompson’s ~1994! view is primarily a two-
Thompson states that these neurophysiologi-
factor theory of emotion wherein it is as-
cal constituents, for example, neuroregulatory
sumed that there are two phenomena: one
functions of the hypothalamus–pituitary–
involving a set of processes related to emotion
adrenal ~HPA! axis, prefrontal cortex ~PFC!,
and the generation of emotion, and the other
or other brain regions and circuits, provide the
involving a different set of processes that man-
basis for more complex forms of emotion man-
age ~or do not manage! the emotion ~Campos,
agement in later years.
Frankel, & Camras, 2004!. The theory sug-
Many of the emotion regulation processes
gests that the process of the management of
described by Thompson seem to be dis-
an emotional response is distinct from the re-
rupted in BPD. There is certainly evidence to
sponse itself. Most, if not all, of the processes
support abnormal neurophysiological constit-

904
K. M. Putnam and K. R. Silk
uents in BPD, and many of these neurophysi-
its that both occur after the presentation of an
ological constituents involve neural regions
emotional stimulus. Cognitive change com-
and processes that are implicated in emotion
prises several tactics, regarded as adaptive,
dysregulation ~e.g., amygdala, orbitofrontal
that are familiar to cognitive therapists ~i.e.,
cortex @OFC#, the HPA axis!. Processes of
“positive interpretation,” “downward social
attention and executive functioning have been
comparison,” “cognitive reframing,” and “re-
shown to be disrupted in BPD ~Lenzenweger,
appraisal”!. Some are described in more psy-
Clarkin, Fertuck, & Kernberg, 2004; Mac-
chodynamic terms, and are considered to be
Coon & Newman, 2005; Monarch, Saykin, &
less adaptive ~i.e., “denial”, “isolation,” “in-
Flashman, 2004; Posner et al., 2002!, al-
tellectualization”!. Response-modulation is dif-
though the role of these factors in the disrup-
ferentiated from cognitive change in that it is
tion in emotion regulation is only beginning
concerned with an actual change in behavior.
to be understood. Cognitive–behavioral treat-
Again, these can be adaptive ~e.g., exercise!
ments of BPD ~e.g., dialectical behavior ther-
or maladaptive ~e.g., substance use, self-
apy! target these voluntary processes with
harm!. Regardless of the level of adaptability,
structured interventions because it is thought
all are considered types of emotion regulation.
that individuals with BPD are impaired in their
A main posit of Gross’ position is that strong
ability to utilize these self-regulatory pro-
emotions may at times be unwelcome, and at
cesses ~Linehan, 1993!.
these times, individuals seek to manage their
Another theorist who has written exten-
emotions ~Gross, 1998a!. Gross maintains that
sively about emotion regulation is James Gross.
antecedent-focused emotion regulation, spe-
He ~1998a, 1998b! has observed that emotion
cifically reappraisal, is the most physio-
can be regulated either by manipulating the
logically beneficial. This is based on several
input to the system ~antecedent-focused emo-
studies of physiology and self-report ~Gross,
tion regulation! or by manipulating its output
1998a; Gross & Levenson, 1993, 1997!. These
~response-focused emotion regulation!. Gross
researchers found that, in general, when sub-
defines emotion regulation as a heteroge-
jects were instructed to inhibit facial expres-
neous set of processes by which individuals
siveness while watching disgusting film clips
influence, consciously and voluntarily, which
~a form of response modulation!, this inhibi-
emotions they have, when they will have them,
tion led to increases in skin conductance and
and how they experience and express these
finger pulse amplitude. This suggests that sup-
emotions ~Gross, 1999!. He writes that these
pression of negative emotion leads to in-
processes can include decreasing, maintain-
creased physiological arousal. Gross ~1998a!
ing, or increasing both negative and positive
also studied the effects of reappraisal ~a form
emotions by using various cognitive pro-
of cognitive change! where subjects were asked
cesses such as rationalization, reappraisal, and
to remain detached from the emotional mate-
suppression. As Table 2 depicts, Gross de-
rial. They found that reappraisal led to de-
scribes five different subtypes of emotion reg-
creases in emotional expressiveness but not to
ulation, with each subtype organized within
increased sympathetic arousal. Therefore,
one of the categories of either antecedent- or
Gross argued that reappraisal may be less costly
response-focused regulation ~see Table 2!.
in terms of long-term physical health than sup-
These subtypes are all effortful and volun-
pressing or inhibiting emotional expression.
tary and are, in many respects, similar to the
This distinction between response modula-
processes described by Thompson ~1994!. In
tion and reappraisal appears relevant in BPD
contrast to Thompson’s model, however, Gross’
because it appears that much of the emotion
depiction of emotion regulation does not in-
regulation strategies that are employed by those
clude any emotive or regulatory processes that
with BPD fall under the heading of response
may preexist or simultaneously exist with the
modulation. Response modulation strategies
emotional process. His model provides rele-
may be more or less effective particularly when
vant detail to the subtypes of “cognitive
the emotional response has intensified to what
change” and “response modulation,” and pos-
is experienced as an unmanageable level. Even

Emotion dysregulation and the development of BPD
905
Table 2. Gross’ types and subtypes of emotion regulation
Type
Subtype
Description
Antecedent
Situation selection
Approaching or avoiding certain people, places, or objects in
focused
order to regulate emotions
Situation modification
Active efforts to modify an emotion-eliciting situation in order
to alter its emotional impact
Attentional deployment
Altering one’s attentional focus with strategies
Distraction: the focus of attention on nonemotional aspects
of a situation
Concentration: the focus of attention on a nonemotional
alternative activity
Rumination: the focus of attention is directed to feelings
and their consequences
Cognitive change
Modifying cognitive evaluations of an emotional stimulus
Evaluation of capacity: evaluating one’s capacity to manage
the perceived situation
Psychological defenses: denial, isolation, and
intellectualization
Positive interpretation: interpreting events more positively
than warranted
Downward social comparison: comparing one’s situation
ith that of a less fortunate person
Cognitive reframing: when one experiences failure with
one goal but reframes this is a success ~or neutral! with
respect to another goal.
Reappraisal: cognitively transforming a situation in an
effort to alter its emotional impact
Response
Response modulation
Directly influencing physiological, experiential, or behavioral
focused
responding
Substances: using drugs, food, or other substances to target
physiological and experiential responses
Activity: using exercise or relaxation to reduce physiological
and experiential aspects of negative emotions
Regulating emotional expression: using expressive behavior
to increase or decrease emotional experience
Self-harm: injuring self to reduce physiological and
experiential aspects of negative emotions
Note: Adapted from Gross ~1998b!.
if the person is able to employ an effective
then may be that by the time they consider
response modulation strategy in that the strat-
employing techniques to reduce emotional in-
egy is able to reduce the intensity of the neg-
put or reaction they are too distressed to uti-
ative emotion, the consequences of some these
lize them or utilization is much less effective
behaviors ~e.g., substance use, self-harm! are
than if the techniques were employed earlier.
dysregulating in and of themselves. Although
The question needs to be asked whether there
cognitive change and attentional deployment
is an earlier point of intervention that would
can modulate emotional input into the system,
improve the success of these regulatory at-
they also occur simultaneous with or after the
tempts. It appears that current treatments,
presentation of an affective stimulus. These
somatic and cognitive, have not been as suc-
latter processes, as with response modulation,
cessful at determining that point as one would
are difficult for individuals with BPD to em-
wish.
ploy successfully when they are severely dis-
Therefore, viewing regulation primarily as
tressed. The problem with patients with BPD
an aftereffect of exposure to an emotional cue

906
K. M. Putnam and K. R. Silk
may obscure the quintessential nature of emo-
regulation is to enhance the good emotions
tion dysregulation observed in BPD. One needs
and attenuate the bad emotions. Although this
also to consider an essential aspect of effec-
is intuitively reasonable and consistent with
tive emotion regulation to be protecting one’s
proponents of “positive psychology” ~see Laz-
self against the onslaught of intense negative
arus, 2003!, Campos and colleagues maintain
emotions in the first place. However, in BPD
that this approach is not appropriate for under-
research, much of the emphasis has been on
standing the functions and mechanisms of emo-
the role of emotion regulation as a tool to
tion regulation.
manage an emotional response rather than as
a process that exists before and0or during an
One-factor models
emotional response. Much of the first-line treat-
ment of BPD is necessarily focused on choos-
Campos and colleagues ~2004! suggest that
ing other, less-lethal, means of responding to
emotion and emotion regulation are concur-
the perceived noxious environment. By elim-
rent, coterminous processes, and they provide
inating the pervasive chaos created by the dan-
a “one-factor” alternative to Thompson and
gerous and ineffective methods of emotion
Gross. They define emotion regulation as “the
regulation ~e.g., “coping” by self-harm, anger
modification of any process in the system that
outbursts, etc.!, it is a believed that a more
generates emotion or its manifestation in be-
paradigmatic course of therapy ~and life! can
havior. The processes that modify emotions
progress. In following this sequence of think-
come from the same set of processes as the
ing, we have perhaps led the proverbial horse
ones that are involved in emotion in the first
to water, and we even suspect that he is able to
place. Regulation takes place at all levels of
drink. However, we remain unclear as to his
the emotion process, at all times the emotion
motivation to drink or why he would not drink
is activated, and is evident before an emotion
in the first place before we went to all this
is manifested” ~Campos et al., 2004, p. 380!.
trouble! Put more succinctly, the specific dys-
They base this model on the writings of Bar-
function in emotion regulation that we see in
rett and Campos ~1987!, Frankel ~1999, 2002!,
BPD remains unclear and undefined, and, at
Frijda ~1986!, and Lazarus ~1991!. These au-
this stage, the data fail to form a coherent
thors do not present emotion and emotion reg-
model. Although we have a point of interven-
ulation as being separate or that emotion
tion ~i.e., the teaching of emotion and behav-
precedes emotion regulation. Rather, they view
ioral regulation skills as we do in DBT;
emotion and emotion regulation as cojoined
Linehan, 1993!, it often feels as if we are
processes that reflect attempts by the person
attempting to throw toward some target in the
to adapt to exogenous situations. These au-
dark as our target is unknown, unclear, or
thors do acknowledge that, although there are
unseen.
examples of the two-step process of emotion
Both Thompson and Gross largely endorse
regulation, these are less frequent than the one-
a two-factor theory of emotion. In a recent
step process of simultaneous emotion0emotion
review, Campos and colleagues ~2004!, sug-
regulation. According to the authors, this one-
gest that the two-factor approach makes intu-
factor alternative model has four qualities: ~a!
itive sense as it follows common lore. That is,
it is more integrative; ~b! it allows one to
we experience intense emotion, and then we
account for context and how a bad emotion
attempt to reduce our emotion by using differ-
can be good in a certain context and vice versa;
ent techniques. For example we “count to ten,”
~c! it allows for social, cultural, and historical
“curb our wrath,” “sleep on it,” “let it go.” We
influences; and ~d! it provides novel heuristic
“do” these things in an effort to manage or
principles that can inform our understanding
reduce the intensity of our emotion. Campos
of the process of emotion development. Table 3
and colleagues propose that a corollary of this
presents a summary of Campos et al.’s ~2004!
is the belief that there are “good” ~e.g., happi-
model.
ness, joy! and “bad” ~e.g., anger, sadness! emo-
As in the two-factor theories of emotion,
tions, and that the implicit goal of emotion
there are ways that this model is applicable to

Emotion dysregulation and the development of BPD
907
Table 3. Campos et al.’s aspects 0characteristics of emotion regulation
Observation
Examples
Mechanism
Emotion regulation
Cortical inhibition ~or
Release of existing cortical inhibition
is evident before an
disinhibition! can pre-
Direct activation of cerebral emotion circuits
emotion is elicited.
cede emotion elicitation.
The end of a sequence can
Assessment of one’s capacities to respond
influence the beginning
to the emotional event
of the next sequence.
The importance of “short-
Cognitive “preappraisal” of emotional stimuli
circuiting” of appraisals
Niche picking: choosing
Avoidance of occasions where undesired
one’s environment
emotion is likely to become activated
influences one’s emotions.
Choosing settings in which the desired
emotion is likely to become activated
The same processes
The person’s goals
Responses selected and deployed are in
that generate
service of goal~s!.
emotions regulate
Expressions of emotion are in service of
them.
goal~s!.
Hedonics
Aversion0desire are mechanisms to monitor
our progress toward goals.
Aspect of an end state
Directly sought experience
Emotional communication
Generate emotion in another
Influence the quality and intensity of another’s
emotion
Means by which the person is embedded in
social contexts and acquires social norms
Play a role in the construction of social
emotions ~e.g., pride, shame, guilt!
Past experiences
Parent–child interaction
Socialization
Cultural rules and norms
Note: Adapted from Campos et al. ~2004!.
the understanding of emotion dysregulation
cess that appears to be at work. This is seen in
and BPD. Recent evidence indicates that there
a variety of ways, most notably in the symp-
are ~a! both structural and functional abnor-
tom of fear of abandonment where the indi-
malities in resting neural function in BPD ~see
vidual anticipates a person’s departure and may
neuroimaging section!, ~b! alterations in HPA
then, in anticipation, experience the complete
axis function in BPD ~Lieb et al., 2004!, and
affective arousal as well as the intolerance of
~c! other neurophysiological factors that would
that arousal. Further, individuals with BPD
influence a tonic inhibition or disinhibition
are impaired in their ability to choose adap-
prior to the experience or expression of the
tive environments where they will have their
emotion ~for review, see Schmahl, McGlas-
emotional needs met and experience positive
han, & Bremner, 2002!. Although not explic-
affect ~Linehan, 1993!. The latter part of Cam-
itly tested, clinical studies of BPD indicate a
pos et al.’s model ~bottom half of Table 3! is
lack of tolerance of emotion that is likely re-
also relevant to understanding emotion dys-
lated to a poor assessment of one’s abilities to
regulation in BPD as these processes have been
deal with an affectively arousing stimulus. In
observed to be disrupted. Goals are unsettled,
BPD, there is often intense affective arousal
likely as a result of identity disturbance; he-
related to the possibility of an emotional stim-
donics are not defined, perhaps through a sim-
ulus occurring, that is, a “preappraisal” pro-
ilar mechanism; emotional communication is

908
K. M. Putnam and K. R. Silk
often exaggerated or inappropriate ~Zanarini
ories, learned helplessness and hopelessness,
& Frankenburg, 1994!; and past experiences
and increased risk for hypertension and car-
are often characterized by invalidating parent–
diovascular disease ~Aldwin et al., 1994; Brem-
child interactions and poor socialization expe-
ner et al., 2004; Charney, 2004!. Similar
riences ~Zanarini et al., 2000!.
symptoms have been found in various stress-
All three models ~Thompson, Gross, Cam-
induced psychiatric disorders in addition to
pos et al.! as presented can apply to our un-
BPD, such as posttraumatic stress disorder
derstanding of the development of emotion
~PTSD!, obsessive–compulsive disorder, and
dysregulation in BPD, but each emphasizes
depression ~Bremner et al., 2004; Shearin &
different aspects of the emotion–emotion
Linehan, 1994!.
regulation process. The strength of both
Despite these discussions of models of emo-
Thompson’s and Gross’s models is the fine-
tion and emotion regulation and despite re-
grained description of various voluntary, con-
search that attempts to explore the role of
trolled strategies for regulating an emotional
emotion regulation in BPD, there are argu-
response. However, in BPD, emotional disrup-
ments made as to whether emotion and emo-
tions appear to be disordered from the very
tion regulation are useful, well-defined and
beginning of the generation of the emotion,
well-informed scientific constructs ~Cole, Mar-
and the one-factor model may be a more use-
tin, & Dennis, 2004!. Regardless of the above
ful one to consider in these people.
arguments, there are also claims that the abil-
ity to regulate one’s emotions is so central to
development that it impacts one’s ability to
Importance of Effective
organize a whole series of internal processes,
Emotion Regulation
which in turn, facilitates aspects of cognition
The benefits of effective emotion regulation
and learning, attention, identity, and social in-
are not only linked to a decreased vulnerabil-
teraction and behavior ~Cole et al., 1994!. We
ity to the development and maintenance of
do not enter into these discussions but pro-
psychopathology, but there are data that sug-
ceed in this paper on the premise that emotion
gest that effective emotion regulation pro-
both has to be regulated and also has regula-
motes both mental and physical stability as
tory activity ~Cole et al., 2004!, and we ex-
well as improvement in overall functioning
plore these issues as they pertain to individuals
~Charney, 2004!. Individuals who display re-
with the diagnosis of BPD. Thus, we examine
silience to stress exhibit personality traits that
the role of emotion and emotion regulation in
contribute to or facilitate effective emotion
affect and in attention in BPD. We will then
regulation. These individuals are character-
look at some of the neurophysiology and neuro-
ized by an optimistic outlook, the perception
anatomy of emotion and turn to how these
that they have control over life events, an ac-
findings inform our understanding of emotion
tive coping style in confronting a stressor, a
in BPD. After reviewing what is known about
positive self-concept, a sense of meaning or
emotion and emotion regulation or response
purpose in life, altruism, and an acceptance of
in BPD, we propose a theory of emotion reg-
social support ~Aldwin, Levenson, & Spiro,
ulation in the development of BPD.
1994; Bremner et al., 2004; Charney, 2004!.
In short, resilient individuals not only recover
Studies of Affect and Affective
from a stressful event; they have the potential
Reactivity in BPD
to transform their interpretation of the event
and view it is an opportunity for personal
It has been hypothesized that the affective re-
growth ~Charney, 2004!.
activity that we observe in BPD is due to a
In contrast, the persistent dysregulation of
acute sensitivity to emotional stimuli ~mainly
emotional responses to stress and negative af-
negative stimuli! that is characterized by
fect that leads to a feeling of chronic stress
heightened emotional intensity and a slow re-
and vulnerability, also contributes to chronic
turn to baseline after emotional arousal ~Line-
anxiety, hypervigilance, fear, intrusive mem-
han, 1993!. Self-report studies have found that

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