After a emotional stimulation, BPD reacts faster and in a more intensive way. That leads to ruminative thoughts as a strategy to regulate emotionality. Rumination intensify the negative emotionality which increase rumination, resulting in a vicious cycle. The dysregulated behavior tends to reduce the intensive emotions reinforcing the problematic behavior and leading to another emotional cascade because of negative emotions of guilt and shame.
From the neuro scientific literature, some evidence supported the ECM.The I cubetheoryofDenson and Pedersenexplains the relationshipbetween Anger Rum and Aggressive Beh in 3 steps.The I cube theory provides neuroscientific evidence that supported the emotional cascade in which the behavior dyscontrol is lead by rumination which consumes neuro-cognitive resources, necessary to manage behaviour.
On the basis of the previous scientific evidence, we have conducted a research involving 3 clinical and research centres
Weseparatelyconductedcorrelational and regressionanalysis on clinical sample and HV to investigate a potentiallydifferentfunctioningbetweengroups.
Aggressionispredictedby ED in bothsamples
When AR isinsert in the modelwith ED, AR ispredictedby ED, but ED looseitssignificance in predicting AQ.ThatmeansthatAR fullymediates the relationshipbetween ED and AB
2- This could be due to the presence of other Cluster B diagnosis among the OPD3-AR is the cognitvemechanismwhichleadsto aggressive behaviour.Evenif ED ispresentitdoesnotmeanthatbehaviouraldyscontrolwillbeshown
EABCT Geneve - Rumination and Behaviour Dysregulation in BPD
Rumination and Behaviour Dysregulationin Borderline Personality Disorder (BPD) Martino F.1-2, Caselli G.2, Menchetti M.1-3, Berardi D.1-3, Sassaroli S.2 1Psychiatric Institute, Bologna University 2Studi Cognitivi, Cognitive Psychotherapy School and Research Centre 3Bologna Mental Health Department
Background Biopsychosocial theory of BPD (Linehan 1993): Dysregulated behaviour = Biological predisposition X Invalidating environment Biological vulnerability: • Heightened sensitivity to emotional stimuli • Experiencing emotions as extremely intense • Slow recovery to emotional baseline Invalidating environment in which communication of emotional experience is met by erratic, inappropriate and extreme responses by others Dysregulated behaviour provides a way to shift attention away from an unpleasant emotional state The specific cognitive mechanisms that cause behavioural dysregulation in BPD are still unclear.
Emotional Cascade Model (ECM) in BPD The Emotional Cascade Model attempts to provide a direct link between emotional dysregulation and behavioral dysregulation in BPD through a process called an “emotional cascade.” BPD patients tend to react faster to emotional stimuli, because of their high sensitivity, which leads to automatic ruminative thoughts. Many people ruminate because they believe (incorrectly) that doing so will increase their understanding of the situation and aid in problem solving (Papageorgiou & Wells 2001, Simpson & Papageorgiou 2003) (positive feedback loop) Rumination has generally been found to magnify negative affect as well as increase its duration (Nolen- Hoeksema 1998; Watkins 2008) (vicious, repetitive cycle) Behavioural dysregulation (self-harm, substance abuse or aggression) would serve as a method of “distraction” that breaks-up the emotional cascade process, due to such an intense ruminative process (relief and reinforce) Following some dysregulated behaviours, BPD may experience another emotional cascade based on negative emotions (e.g. guilt, shame) resulting from the original dysregulated behaviour (increased emotion sensitivity) Selby, Anestis et al. 2008, 2009
Emotional Cascade Model (ECM) Selby, Anestis et al. 2008, 2009 Positive feedback loop EMOTIONAL Vicious cycle EMOTIONAL SENSITIVITY RUMINATION STIMULI SHAMEGUILT ET. Shame and guilt DYSREGULATED Reduce emotionality Perpetuate the cycle BEHAVIOUR and reinforce the cycle
Research evidence on healthy students with BPD traits BPD features are significantly related to both depressive and anger rumination and this relationship is not attributed to depression, anxiety and stress. The Association with BPD features was stronger for anger rumination than for depressive rumination (Bear et al 2011) BPD traits demonstrated greater reactivity and intensity of negative affect following the rumination induction than control subjects without BPD traits (Selby et al 2009) Anger rumination predicted verbal and physical aggression tendency, even after controlling for depression and anxiety symptoms (Anestis et al 2008) General Rumination mediated the relationship between psychological distress (anxiety and depression symptoms ) and dysregulated behaviour (Eating behaviour, Urgency, Substances abuse) (Selby et al. 2008)
3 Neuroscientific evidence: The I Theory I3 theory suggests that anger-inducing provocation leads to angry rumination (with self- regulation property) Self regulation is costly in terms of neuro-cognitive resource because it requires: (a) managing the intensity of the anger experience, b) suppressing angry thoughts, and (c) inhibiting aggressive behaviour. Sufficient glucose must be available to the brain to engage in self-controlled behaviour (Baumeister, 1998; Hagger et al., 2010) (Gailliot 2008, 2007). The self-regulation effort through rumination consumes neuro-cognitive resourse and reduces self-control, increasing the probability that individuals will be less able to control their behaviour. Denson et al. 2008, 2011; Pedersen et al. 2011
Research Settings and Aims Settings: 1. Studi Cognitivi, Cognitive Psychotherapy and Research Centre 2. Mental Health Community Centre of Bologna 3. Psychiatric Institute, Bologna University Aims:1. Assess anger rumination in clinical population (BPD and other PDs) and in healthy volunteers2. Verify that Anger Rumination mediates the relationship between Emotional Dysregulation and Aggressive Behaviour
Methods: Patients and HV enrolled in the study were asked to fill in a consent form and proceed to a psychometric evaluation: Structured Clinical Diagnostic Interview for DSM-IV – Axis II (SCID-II) Borderline Personality Disorder Check List (BPDCL) is a self-report questionnaire for screening people with BPD. Anger Rumination Scale (ARS) to assess the Anger Rumination which is: (1) the tendency to ruminate on anger (2) focusing attention on angry moods (3) recalling past anger episodes (4) thinking about the causes and the consequence of anger episodes Aggression Questionnaire (AQ) to assess the tendency to Aggression which is expressed by (1) feelings of rage (2) hostility (3) verbal aggression (4) physical aggression Difficulties in Emotion Regulation Scale (DERS) to assess the Emotion Regulation which is (1) awareness, understanding and acceptance of emotions (2) ability to engage in goal-directed behaviour when experiencing negative emotions; (3) flexible use of appropriate strategies to modulate the intensity and duration of emotions (4) willingness to experience negative emotions
Sample 93 subjects: 23 patients with BPD 26 patients with OPD ( 5 Cluster A; 9 Cluster B; 12 Cluster C) 44 healthy volunteers (HV) 3 patients were excluded for incomplete data 25% Average Age: 33 47% Sex: 75% female and 25% male 28% BPD OP 3 sub-samples were similar for age [F:083; p: 0.44] D and sex [F:2.15; p:0.12]
Results: ANOVA Slightly signicant difference in ARS between BPD and OPD (p< 0.059) and significant difference in ARS between clinical samples and HV ( p<0.00) Signicant difference in DERS both between BPD and OPD (p< 0.02) and between clinical samples and HV( p<0.00) Signicant difference in AQ both between BPD and OPD (p< 0.00)and between clinical samples and HV( p<0.00) TEST SUB-SAMPLES MEAN SIG. DIFFERENCE BPD- OPD 4.66 0.05 ARS BPD- HV 10.11 0.00 OPD-HV 5.44 0.00 BPD- OPD 18.02 0.02 DERS BPD- HV 34.79 0.00 OPD-HV 16.76 0.01 BPD- OPD 19.69 0.00 AQ BPD- HV 44.08 0.00 OPD-HV 24.39 0.00
Results: Correlational AnalysisBecause of small size of clinical sub-samples we merged BPD with OPDFinal clinical sample (CS) is composed of 49 patients with PDs Analysis showed significant correlations between all measures in the clinicalsample (Ranging from .32 to .55) Analysis showed significant correlations between all measures in healthyvolunteers (Ranging from .47 to .63)
Conclusion Clinical sample showed a greater impairment in emotion regulation, in anger rumination and in aggressive behaviour than the control group. Slight significant differences were noted in Anger Rumination between BPD and OPD In both samples (CS and HV) Emotion Dysregulation predicted the Aggressive Behaviour, but this relationship is fully mediated by anger rumination
Limitations and Future Research Because of small clinical samples we merged BPD and OPD. Future research should be conducted on larger sample of BPD patients Other forms of rumination should be explored in BPD in relation to behaviour and anxiety and depressive symptoms Forms of Dyscontrolled Behaviour (Aggressive acts, self-harm, binge eating) should be considered in future research
Clinical Implications Empirically supported treatment for BPD (DBT, MBT) may implicitily address rumination through mindfullness training or reflection on mental states (Selby et al 2009) More explicit techniques for rumination should be studied in treatment of BPD: Rumination focused CBT (Watkins et al 2007) Metacognitive therapy (Wells 2000) Mindfullness- based cognitive therapy (Segal et al 2002)
Thank you for your partecipation Francesca Martino Cognitive Psychologist Cognitive Psychotherapy School Studi Cognitivi, Modena, Italy Institute of Psychiatry, Bologna University, Italy Email contact: firstname.lastname@example.org