Emotion Differentiation as a Protective Factor Against NonsuicidalSelf-Injury in Borderline Personality Disorder
Landon F. ZakiYeshiva University
Karin G. CoifmanKent State University
Eshkol RafaeliBar-Ilan University
Kathy R. BerensonGettysburg College
Geraldine DowneyColumbia University
Evidence that nonsuicidal self-injury (NSSI) serves amaladaptive emotion regulation function in borderlinepersonality disorder (BPD) has drawn attention to processesthat may increase risk for NSSI by exacerbating negativeemotion, such as rumination.However, more adaptive formsof emotion processing, including differentiating broademotional experiences into nuanced emotion categories,might serve as a protective factor against NSSI. Using anexperience-sampling diary, the present study tested whetherdifferentiation of negative emotion was associated withlower frequency of NSSI acts and urges in 38 individualswith BPD who reported histories of NSSI. Participantscompleted a dispositional measure of rumination and a21-day experience-sampling diary, which yielded an index of
The authors wish to thank Marget Thomas Fishman, M.A., ofRutgers University for her assistance in data collection, and JamilZaki, Ph.D., of Stanford University for his helpful comments onearlier versions of this manuscript.
negative emotion differentiation and frequency of NSSI actsand urges. A significant rumination by negative emotion dif-ferentiation interaction revealed that rumination predictedhigher rates of NSSI acts and urges in participants withdifficulty differentiating their negative emotions. The resultsextend research on emotion differentiation into the clinicalliterature and provide empirical support for clinical theoriesthat suggest emotion identification and labeling underliestrategies for adaptive self-regulation and decreasedNSSI riskin BPD.
BORDERLINE PERSONALITY DISORDER (BPD) is charac-terized by pervasive emotion regulation difficultiesand behavioral impulsivity. Nonsuicidal self-injury(NSSI) typifies both of these features, as accumu-lated evidence documents the emotion regulatingproperties of this maladaptive behavior (Brown,Comtois, & Linehan, 2002; Kemperman, Russ, &Shearin, 1997; Kleindienst et al., 2008). AlthoughNSSI is estimated to occur in 70–80% of thosediagnosed with BPD (Clarkin, Widiger, Frances,
Hurt, & Gilmore, 1983), not all individuals withBPD respond to intense negative emotions with self-injury. Understanding the psychological risk andprotective factors that contribute to the variabilityin frequency of NSSI among people with BPDremains an underexplored area with significantimplications for treatment.The present study examined how individual dif-
ferences in two relevant psychological processes—rumination and emotion differentiation—mightelucidate the hypothesized connection betweenemotional and behavioral dysregulation in adultswith BPD who reported histories of NSSI (Linehan,1993; Selby & Joiner, 2009). Specifically, we pre-dicted that differentiating broad emotional experi-ences into nuanced emotion categories—termed“emotion differentiation” or “emotional granularity”(Barrett, 1998; Barrett, Gross, Christensen, &Benvenuto, 2001)—would moderate the relationshipbetween rumination andNSSI in thosewith BPDwhoreported histories of NSSI.
rumination as a psychological risk factor
for nssi in bpd
Recent theoretical models implicate the cognitivestyle of rumination in the link between emotiondysregulation and NSSI in BPD (Selby, Anestis, &Joiner, 2008; Selby & Joiner, 2009). Building onextensive prior work connecting rumination toNSSI and other self-destructive behaviors (e.g.,bulimia, binge eating, and substance abuse;Heatherton & Baumeister, 1991; Nolen-Hoeksema&Harrell, 2002; Nolen-Hoeksema, Stice, Wade, &Bohon, 2007), the emotional cascade model pro-posed that rumination mediates between emotionaland behavioral dysregulation in BPD (Selby &Joiner, 2009). According to this theory, ruminationon negative emotion progressively builds emotionalintensity in BPD via a positive feedback mechanism.If uninterrupted, emotional intensity continues toincrease and ultimately reaches a level at whichadaptive emotion coping strategies—such as cogni-tive reappraisal or behavioral distraction—fail toeffectively reduce it. Individuals caught in the heightof emotional cascades become increasingly prone toviewing extreme behavioral distractions, includingNSSI, as options for short-circuiting the emotionalcascade. By engaging in NSSI, individuals with BPDprovide negative feedback to the emotional cascade,halt the ruminative process, and reinforce NSSI asan emotion coping tool (Selby & Joiner, 2009).Consistent with the emotional cascade theory,
recent empirical work has linked rumination toNSSI and to BPD more broadly. Investigators havefound significantly higher levels of rumination inindividuals diagnosed with BPD when compared
with individuals diagnosed with depression, and astronger association between rumination and BPDsymptoms than with symptoms of any other per-sonality disorder, even when controlling for de-pression (Abela, Payne, & Moussaly, 2003; Smith,Alloy, & Abramson, 2006). Rumination has alsobeen specifically related to NSSI. Studies havefound that rumination increases vulnerability toNSSI in college students (Armey & Crowther,2008) and moderates the association betweendepressive symptoms and engaging in NSSI for“automatic positive reinforcement” reasons (e.g.,to attain a desired physiological state) in youngadolescent girls (Hilt, Cha, & Nolen-Hoeksema,2008; Nock & Prinstein, 2004). Taken together,these findings suggest that ruminative attention tonegative emotion is associated with greater risk ofdysfunctional self-regulatory strategies includingNSSI, perhaps because it taxes the cognitive re-sources needed for more adaptive emotion regula-tion and problem solving.
not all attention to emotion iscreated equal
Attention to one’s negative emotional states, how-ever, does not invariably lead to such maladaptiveoutcomes. Clinical theories suggest that the specificway in which one attends to negative emotionalstates can moderate the impact of these emotionson experience and behavior (Beck, Rush, Shaw, &Emery, 1979; Hayes, Strosahl, & Wilson, 1999;Linehan, 1993). Both cognitive-behavioral therapyand emotion-focused therapies (e.g., dialecticalbehavior therapy, acceptance and commitmenttherapy) teach strategies such as cognitive restruc-turing and mindfulness to alter one’s experience ofemotional states. Research supports the notion thatspecific types of attention to emotion are differen-tially associated with maladaptive rumination andadaptive reflection. For example, a series ofexperiments conducted on both clinically de-pressed and nonclinical populations has demon-strated that focusing on the reasons underlying anegative emotional experience from a “distanced”third-person perspective decreases negative emo-tion intensity and rumination (Kross, Ayduk, &Mischel, 2005; Kross, Gard, Deldin, Clifton, &Ayduk, 2012). By contrast, reimmersing oneself inthe emotional experience while focusing on thedescriptive features of the experience increasesrumination and intensity of negative emotion.These findings offer hope for teaching individualswith BPDmethods to interrupt emotional cascades,and by extension, deter the selection of maladap-tive strategies like NSSI to manage intense emo-tional experiences.
531emot ion d i f ferent i a t ion and self - i n jury in bpd
emotiondifferentiation as a psychologicalprotective factor against nssi in bpd
One type of attention that may, in fact, helpindividuals with BPD break the cycle of ruminationon negative emotion is emotion differentiation.Emotion differentiation, also known as emotionalgranularity, describes the ability to make fine-grained distinctions between similarly valencedstates (Barrett, 1998; Barrett et al., 2001). Indi-viduals differ widely in their emotion differentiationcapacities; whereas some people frequently distin-guish between emotional states with similar valence(e.g., sadness, anger), others tend to describe theiremotional experience in more global terms (e.g.,feeling “good” vs. feeling “bad”). These tendenciesare influenced largely by the degree to which oneemphasizes the valence property (pleasantness orhedonic value) versus the arousal property (bodilyactivation) in their representation of emotion(Barrett, 1998). Individual differences in differenti-ation can be captured through daily diary methods.Investigators who use such methods assess indi-viduals’ experience of multiple discrete emotions,across a period of time, and take the correlationsamong similarly valenced emotions (e.g., sadness,anger, nervousness) as a single individual differencemeasure of differentiation (Barrett et al., 2001;Kashdan, Ferssizidis, Collins, & Muraven, 2010;Pond et al., 2012; Tugade, Fredrickson, & Barrett,2004). High emotion differentiators evidence smallercorrelations among negative states such as anger,sadness, and nervousness, while low emotion differ-entiators demonstrate large positive correlationsamong such similarly valenced emotions. Critically,low differentiators—those who likely focus solely onthe valence property (e.g., pleasantness vs. unpleas-antness) of their emotional lives—may lose impor-tant information about their emotional experiences,and may therefore be less adept at effectivelyresponding to those experiences.Research on emotion differentiation holds impor-
tant implications for emotion regulation in BPDbecause differentiation appears to support emotionregulation, especially at higher levels of emotionalintensity (Barrett et al., 2001; Kang& Shaver, 2004;Tugade et al., 2004). For instance, Barrett andcolleagues (2001) found that high differentiatorsreported more frequent use of several adaptiveemotion regulation strategies (e.g., distraction, self-soothing), particularly when emotional intensity washigh and the need for emotion regulation wasgreatest. This is consistent with recent work, whichdemonstrated that emotion differentiation mediatedthe relationship between emotional lability andmindfulness (Hill & Updegraff, 2012) and thatemotion labeling reduced fear responding in spider-
fearful individuals during an exposure exercise(Kircanski, Lieberman, & Craske, 2012).Despite the growing evidence for an association
between emotion differentiation and regulation, theclinical implications of this work have only recentlybegun to be explored. Recent studies suggest thatimpairments in negative emotion differentiationcharacterize individuals with major depressive dis-order (Demiralp et al., 2012) and that effectivenegative emotion differentiation is associated withless frequent maladaptive behaviors, includingbinge drinking following intense negative affect(Kashdan et al., 2010) and aggression followinganger (Pond et al., 2012). These studies suggest thatemotion differentiation may offer resiliency againstdysregulated behaviors in emotionally at-risk indi-viduals; as such, they seem especially pertinent tothe understanding of NSSI in BPD.To date, only one study has directly examined
emotion differentiation in BPD. Suvak and colleagues(2011) found that, relative to controls, females withBPD demonstrated poorer differentiation of emo-tions, contributing to an “all-or-nothing” pattern ofemotional responding common to BPD. Thesefindings dovetail with evidence that individuals withBPD, or those high in BPD traits, are impaired inseveral constructs related to emotion differentiation—including emotional awareness, emotional clarity,and capacity to coordinate mixed-valence feelings(Coifman, Berenson, Rafaeli, & Downey, 2012;Conklin, Bradley, & Westen, 2006; Leible & Snell,2004; Levine, Marziali, & Hood, 1997). Still, therole of emotion differentiation in preventing mal-adaptive behaviors in BPD, as well as interactionsbetween differentiation and other forms of attentionto emotion, have yet to be explored.
current investigation
Using an experience-sampling method, the presentstudy directly assessed the role of rumination andemotion differentiation in predicting NSSI in adultswith BPD who reported histories of NSSI, using anexperience-sampling method. In addition to provid-ing a standard measure of differentiation (Barrett etal., 2001; Kashdan et al., 2010; Pond et al., 2012;Tugade et al., 2004), experience-sampling methodsoffer many advantages over traditional self-reportstudies. These methods obviate retrospective biasesinherent in self-report research and provide greaterecological validity, an issue particularly relevantwhen studying an emotionally intense and labilepopulation such as BPD.Three hypotheses guided this study. Our first
hypothesis addressed both the group of participantswith BPD and histories of NSSI (hereafter labeled the“BPD group”) and a nonclinical control group. The
Table 1Characteristics of Study Participants (N = 80)
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remaining two hypotheses concerned only the BPDgroup. First, we hypothesized that participants withBPD who reported histories of NSSI would havehigher rumination and lower negative emotiondifferentiation scores than controls. Second, wehypothesized that, within the BPD group, ruminationwould be associated with a higher frequency of NSSIacts and urges reported across the experience-sam-pling period. Finally, we hypothesized that negativeemotion differentiation would moderate the relation-ship between rumination andNSSI in the BPD group,in essence buffering ruminating individuals fromturning to NSSI as a regulatory strategy.Though our main hypotheses concern only the
BPD group, we elected to include a nonclinicalcontrol group in this study for several reasons. Thecontrol group not only illuminates differences inrumination between BPD and healthy control (HC)participants but also assists readers in interpretingdifferences in emotion differentiation, a relativelynovel construct within the clinical literature. More-over, inclusion of a nonclinical control groupreplicates the design of the only existing study onemotion differentiation in BPD (Suvak et al., 2011).
Methodparticipants
Participants who met criteria for a current DSM-IVdiagnosis (DSM-IV-TR; American PsychiatricAssociation, 2000) of BPD and HC participantswere recruited as part of a larger study on BPD(Berenson, Downey, Rafaeli, Coifman,& Leventhal,2011; Coifman et al., 2012). In total, 81 individualswho met current diagnostic criteria for BPD wererecruited for the larger study. Within this sample, weidentified a subsample of 54 individuals with BPD(67%) who met the inclusion criteria for this studyand also endorsed a history of NSSI either during thediagnostic interview or on a self-report measure ofNSSI (described below). However, because ofdropout, equipment malfunction, and/or insufficientdata, 16 of the 54 BPD participants were excludedfrom this investigation, resulting in a total of 38 BPDparticipants for the current study sample.1 This BPD
1Of the 16 participants who were excluded, 9 were excluded forinsufficient data unrelated to the diary (e.g., dropout, failure tocomplete the rumination measure). We followed standard experience-sampling analysis procedures to determine sufficient number of diaryentries and excluded four participants for whom the number ofcompleted diary entries was fewer than 25, or two standard deviationsbelow themeanof the original sample (Bolger,Davis,&Rafaeli, 2003).These excluded participants completed 0, 6, 15, and 22 entries,respectively. The remaining 3 excluded participants either failed tocomplete the diary or experienced equipment malfunction. There wereno significant demographic or diagnostic differences between our finalsample and those individuals whowere excluded from the final samplebecause of dropout, equipment malfunction, or insufficient data.
sample was 84% female and had a mean (SD) age of29.89 (10.60). To compare levels of rumination andemotion differentiation in BPD to those found inhealthy participants, we also recruited 42 HCparticipants (83% female) with a mean (SD) age of32.50 (7.53).Printed flyers, newspaper advertisements, and
postings on mental health Web sites were used torecruit participants. All participants were inter-viewed with the Structured Interview for DSM-IVPersonality (SIDP-IV; Pfohl, Blum, & Zimmerman,1997) to determine the presence of Axis IIpersonality disorders, and with the StructuredClinical Interview for DSM-IV Axis I Disorders(SCID-I; First, Gibbon, Spitzer, & Williams, 1996)to assess the presence of Axis I pathology.Exclusion criteria for both groups included evi-dence of a primary psychotic disorder, currentsubstance intoxication or withdrawal, cognitiveimpairment, or illiteracy. For the BPD group,relatively few exclusion criteria were used giventhe high rates of co-occurring disorders in thispopulation (Shea et al., 2004; Skodol et al., 2002),as well as frequent utilization of psychotherapy andpsychiatric medication.For the HC group, several exclusion criteria were
used. HC participants were excluded if they metmore than 2 criteria for any personality disorder ormore than 10 criteria across all personalitydisorders. In addition, participants were excludedfrom the HC group if they had current or partiallyremitted Axis I diagnoses in the year prior tointerview date, took psychiatric medication, orhad SCID-I Global Assessment of Functioningscores lower than 80. Finally, HC participantswere excluded if they reported any history of self-injurious behavior. The BPD and HC groupsdid not differ significantly in age, gender, orracial/ethnic composition (Table 1); however, theBPD group completed significantly fewer years of
Note. BPD = borderline personality disorder; HC = healthy control.
533emot ion d i f ferent i a t ion and self - i n jury in bpd
education, M(SD) = 15.21 (2.30), compared to theHC group, M(SD) = 17.80 (2.41), t(78) = 4.92,p b .001. Table 2 lists co-occurring Axis I diagno-ses for the BPD group.
procedure
All callers responding to study ads were prescreenedover the phone using questions adapted fromthe Structured Clinical Interview for DSM-IV-II(SCID-II; First, Gibbon, Spitzer, Williams, &Benjamin, 1997). Because preliminary work indicat-ed that requiring six rather than five criteria on thephone screener yieldedmore true positives during thediagnostic interview, callers were required to endorseat least six of nine BPD criteria on the phone screenerin order to be invited for an in-person diagnosticinterview (for which they received compensation of$30). Following the interview session, eligibleparticipants were given a questionnaire packet tocomplete at home. The packet contained the self-report measures for rumination and NSSI, inaddition to measures pertinent to the hypotheses ofthe larger study. Participants returned their complet-ed questionnaires at a second session and weretrained by the study coordinator to use the electronicdiary. The study coordinator ensured participantsunderstood all diary instructions and questions byobserving them complete their first electronic diaryentry in the lab. Participants were additionally givena written manual that provided clarifications tocommon diary misunderstandings, and they wereinformed that a research assistant would contactthem weekly in order to encourage compliance andanswer questions. After the 21-day diary period wascompleted, participants returned the electronic diaryto the lab, were debriefed, and paid for their
Table 2Current Co-occurring Axis I Diagnoses for the BPD Group
Axis I diagnosis BPD (n = 38)
n %
Major depressive episode 19 50Bipolar I or II disorder 4 11Dysthymic disorder 7 18Social phobia 18 47Posttraumatic stress disorder 11 29Panic disorder, agoraphobia, or both 5 13Obsessive-compulsive disorder 3 8Generalized anxiety disorder 17 45Bulimia nervosa 2 5Binge eating disorder 2 5Substance dependence or abuse a 12 32
Note. BPD = borderline personality disorder.a Includes the following: alcohol, cannabis, cocaine, hallucinogen,
opioid, sedative/hypnotic/anxiolytic, stimulant.
participation. Participants were paid $1 per diaryentry completed, with the possibility of earning amaximum of $100 for the experience-samplingportion of the study. Written informed consent wasobtained prior to the diagnostic interview, and allaspects of the research were approved by theuniversity Institutional Review Board.
Diagnostic InterviewsAll participants were administered the SIDP-IV(Pfohl et al., 1997), a semistructured interviewdesigned to assess the presence of Axis II person-ality disorders. Additional evaluation was con-ducted using the SCID-I (First et al., 1996).Participants were included if they met study criteriafor BPD and also endorsed a history of NSSI oncriterion 5 of the SIDP-IV diagnostic interview. Toassess self-injury history, participants were asked:“Have you ever been so upset or tense that youdeliberately hurt yourself by cutting your skin,putting your hand through a glass window, burningyourself, or anything else like that? What have youdone? How often?”We calculated interrater reliability for both diag-
nostic interview measures as follows: five video-taped interview sessions, including both SIDP-IVand SCID-I interviews, were randomly selected bythe diagnostic interview coordinator, a doctoral-level clinical psychologist with extensive diagnosticinterview experience. All other study interviewers,who were doctoral-level clinical psychologists andclinical psychology graduate students, blindly codedboth interview measures for these five randomlyselected sessions. Interviewer ratings were thencompared with the ratings of the diagnostic inter-view coordinator to calculate a kappa coefficient.Interrater reliability was assessed at both the symp-tom level for BPD (κ = 0.83) and for all SCID-Idiagnoses reported in Table 2 (κ = 0.86).
Inventory of Statements about Self-Injury (ISAS)Participants who met study criteria for BPD andendorsed a lifetime history of NSSI on the ISAS(Klonsky & Glenn, 2009) were also included in theBPD group. The ISAS is a self-report measureassessing NSSI methods, lifetime frequency, andNSSI functions. Participants were asked to estimatethe number of times in their life they hadintentionally (i.e., on purpose) performed 12 typesof self-injury (e.g., cutting, burning, banging, orhitting self). This measure defines self-injury forparticipants as a behavior done “intentionally” and“without suicidal intent.” The ISAS has demon-strated excellent internal consistency, concurrentvalidity, and adequate test–retest reliability for theNSSI behaviors assessed (Glenn & Klonsky, 2011;Klonsky & Glenn, 2009).
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Ruminative Responses Scale (RRS)Rumination was assessed with items from theBrooding subscale of the Ruminative ResponsesScale (RRS; Nolen-Hoeksema & Morrow, 1991;Treynor, Gonzalez, & Nolen-Hoeksema, 2003).Participants rated on a 4-point Likert scale (1 =almost never, 4 = almost always) how often theyengaged in a list of thoughts and behaviors whenfeeling down or depressed. Recent reanalysis of theRRS indicated that the Brooding subscale aloneuniquely captures the process of passive, maladaptiverumination on the causes and consequences of one’sdistress (Armey et al., 2009; Treynor et al., 2003). Thefive items comprising this subscale (α = .89) assesshow often individuals engage in behaviors such as“Thinking ‘what am I doing to deserve this?’” whenfeeling down or depressed.
experience-sampling diaryNegative Emotion DifferentiationDifferentiation of negative emotion was assessedusing a 21-day computerized experience-samplingdiary. Handheld Zire 21 personal digital assistantsconfigured with the Intel adaptation (iESP) of theExperience-Sampling Program software (ESP;Barrett & Barrett, 2000) emitted signals at randomintervals five times daily for a period of 21 days. Allresponses were automatically dated and timestamped by the software program.At each electronic diary entry, participants rated
on a 5-point Likert scale (1 = not at all, 5 =extremely) the extent to which they were currentlyexperiencing a list of distinct negative emotions. Theemotions included afraid, angry, ashamed, disap-pointed, irritated, sad, and tense. Intermixed withthese emotion words, participants also rated anumber of positive emotions (e.g., satisfied, energetic,happy, enthusiastic, relaxed, grounded, calm, andself-confident), which were not included in thecalculation of the negative emotion differentiationindex. These particular negative and positive emo-tion terms were selected to account for varying levelsof activation across positive and negative valences, assuggested by affective circumplex models (e.g.,Rafaeli, Rogers, & Revelle, 2007; Russell, 1980).From the ratings of the negative emotion terms, wederived a negative emotion differentiation index foreach participant by calculating the within-personaverage interitem correlations (AICs) between allpossible pairs of emotion items across all diaryentries (Barrett et al., 2001; Kashdan et al., 2010;Pond et al., 2012; Tugade et al., 2004). The AICswere then normalized using Fisher r-to-z transfor-mations and reversed so that large values wouldcorrespond to high emotion differentiation and smallvalues would correspond to low emotion differenti-
ation (Kashdan et al., 2010). Reliability coefficientsfor the negative emotion differentiation index werecomputed at the between-subject level, .90 (i.e.,reflecting the ability to reliably differentiate betweenparticipant scores during a single fixed diary entry)and at the within-subject level, .82 (i.e., reflecting theability to reliably detect change in a participant’sscores across assessments; see Cranford et al., 2006).
NSSI Acts and UrgesNSSI acts and urges were also assessed at eachelectronic diary entry with the following prompt:Please indicate whether you injured yourself directlysince the last diary. Participants were then asked toselect a response from the following options:No;No,but I thought about it; No, but I had a strong urge; orYes. Self-injury was defined for participants as “anybehavior that causes direct tissue damage such ascutting, banging, burning, or scratching.”During thediary training session, the study coordinator ensuredthat participants understood this behavior to bedistinct from both suicidal behavior and accidentalself-injurious behavior. In addition, all participantswere given a written document containing the exactdiary questions in the study, along with definitionsand explanations for each question. A single meanNSSI variable combining both NSSI acts and NSSIurges was then calculated for each participant bysumming all reported NSSI acts and urges for thatparticipant across the diary period. Thoughts aboutNSSI were not included in our dependent variable.
Resultsanalyses involving the bpd andhc groups
The BPD and HC groups completed a mean (SD) of75.71 (20.51) out of a possible 105 diary entries(range 27–105). The number of diary entriescompleted by the BPD group (M = 75.47, SD =22.12) did not differ significantly from the HCgroup (M = 75.93, SD = 19.20), t(70) = 0.10, ns,nor did the number of days in which participantsactively responded to the diary prompts across the21-day period (BPD: M = 19.89 days, SD = 2.17;HC: M = 20.19 days, SD = 1.97, t(78) = .64, ns).Our first hypothesis proposed that the BPD group
would be higher in rumination and lower in negativeemotion differentiation relative to the HC group. Aspredicted, we found that the BPD group reportedsignificantly higher levels of rumination (M = 3.22,SD = 0.64) than the HC group (M = 1.71, SD =0.60), t(78) = –11.06, p b .001. The BPD groupalso evidenced significantly lower negative emotiondifferentiation scores (M = 0.55, SD = 0.15),reflecting poorer discrimination of negative emo-tions relative to the HC group (M = 0.81, SD =0.13), t(78) = 8.32, p b .001. Across the diary
Table 3Hierarchical Regression Predicting Diary-Reported NSSI in the BPD Group (N = 38)
Note. BPD = borderline personality disorder; NSSI = nonsuicidal self-injury.*p b .05; **p b .01.
2We were particularly interested in ruling out the effect of meanlevels of negative affect, since one alternative explanation for ourfindings was that individuals more able to differentiate negativeemotion would also report lower levels of negative affect. However,when we entered this variable into our regression analysis, it wasnot a significant predictor, β = .23, p = .16, and did not influencethe significance or strength of the interaction between ruminationand negative emotion differentiation when predicting NSSI acts andurges.
535emot ion d i f ferent i a t ion and self - i n jury in bpd
period, the BPD group reported amean (SD) of 1.03(2.06; range 0–8) NSSI acts, a mean (SD) of 1.53(3.49; range 0–15) NSSI urges, and a combinedNSSI acts and urges mean (SD) of 2.55 (4.83; range0–23). As we anticipated, there were no reports ofNSSI acts or urges from the HC group.
analyses involving the bpd group only
Our remaining two hypotheses solely concerned theBPD group. Within this group, we proposed thathigher rumination would be associated with a greaterfrequency of NSSI acts and urges and that negativeemotion differentiation would moderate the asso-ciation between rumination and NSSI. We firstexamined the variables of interest using bivariatecorrelations and found a nonsignificant correlationbetween rumination and negative emotion differen-tiation, r = –.13, ns. In addition, we systematicallychecked that assumptions of regression were notviolated, including visually inspecting residuals andconfirming the linearity and normality of thedistribution for all relevant variables. Moreover, weused a square root transformation on the dependentvariable (summed NSSI acts and urges), which wasskewed, so that these data approximated a normaldistribution (e.g., NSSI acts and urges skewness =1.08). We then centered rumination, negative emo-tion differentiation, and the interaction of ruminationby negative emotion differentiation and tested ourhypothesis using one hierarchical regression. In thefirst step, we entered rumination, negative emotiondifferentiation, and number of diary entries aspredictor variables, with the log transformation ofNSSI acts and urges as our dependent variable. In thesecond step, we added the interaction term ofrumination and negative emotion differentiation.Contrary to our prediction, we did not find asignificant main effect for rumination. However, asexpected, the results indicated a significant interactionbetween rumination and negative emotion differen-tiation, β = –0.47, p b .01 (Table 3), which we then
probed by graphing the predicted values at onestandard deviation above and below the mean forboth rumination and negative emotion differentiation(Figure 1).A follow-up test of the simple slopes indicated
that the association between rumination and NSSIunder high negative emotion differentiation (onestandard deviation above the mean for the BPDgroup) was significantly different from zero, β =–0.35, p b .001. The association between rumina-tion and NSSI under moderate negative emotiondifferentiation (one standard deviation below themean for the BPD group and therefore not consid-ered “low” per se) was also significant, β = 0.22,p b .05, demonstrating the inverse relationship.Thus, for participants with high rumination, highdifferentiation of negative emotion was associatedwith significantly decreased frequency of NSSI,whereas low differentiation of negative emotionwas associatedwith significantly increased frequencyof NSSI. In effect, negative emotion differentiationprotected these individuals from the behavioral costsof rumination.Finally, we examined the effects of potential third
variables that could have important associationswith NSSI acts and urges. These included meanlevels of negative affect across the diary,2 currentdiagnosis of major depressive disorder or dysthymicdisorder, as well as age, years of education, andcurrent treatment with psychotherapy or psychiat-ric medication. None of these variables had any
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FIGURE 1 The interaction of rumination and negative emotiondifferentiation when predicting the sum of NSSI acts and urgesacross the three-week diary period in BPD participants whoreported histories of NSSI.
536 zak i e t al .
meaningful effect on our results and were thereforenot considered further.
DiscussionThe present study clarifies the role played by twopsychological processes—rumination and emotiondifferentiation—in predicting self-injury in adultswith BPD who reported histories of NSSI. Specif-ically, the interaction between the two processeswas significantly associated with self-injurious actsand urges in BPD participants with histories ofNSSI. These results held even when controllingfor important covariates such as mean levels ofnegative affect and current diagnosis of depressionor dysthymia.Whereas prior research has implicatedrumination in NSSI, our data suggest that thecombination of these two emotional processesmay better account for the frequency of NSSI inBPD. Specifically, our findings suggest that theassociation between rumination and NSSI acts andurges is moderated by negative emotion differentia-tion. Indeed, the ability to differentiate negativeemotional experiences may be protective, as partic-ipants who demonstrated greater differentiationamong their various negative emotions reportedfewer self-injurious acts and urges, even when proneto high levels of rumination.Building upon the growing literature linking
rumination to self-injury (Armey & Crowther,2008; Hilt, Cha, et al., 2008), the present studyprovides preliminary evidence that the associationbetween rumination and NSSI may be contingenton other emotional processes, such as emotiondifferentiation. Although a significant main effectof rumination on NSSI was predicted, this predic-tion was not supported. Insufficient variance dueto elevated levels of rumination in nearly all ofthe BPD participants, compared to the controls,may have masked a main effect for rumination.Nonetheless, this study helps further elucidate the
nature of the relationship between rumination andNSSI, and represents the first study to examinerumination in tandem with the process of emotiondifferentiation.These data also extend recent demonstrations of a
link between high levels of rumination and BPD(Abela et al., 2003; Smith et al., 2006). Our workbuilds on Selby and Joiner’s (2009) emotionalcascade model of BPD by proposing one method ofattending to emotions—emotion differentiation—that may protect ruminating individuals with BPDfrom engaging in NSSI. Specifically, we posit thatwhen individuals are immersed in an emotionalcascade, the extent to which they label and distin-guish the specific negative emotions experiencedmaydecrease the likelihood that they will use NSSI tobreak this recursive ruminative cycle. This hypothesisis supported by a wealth of experimental andneuroimaging work suggesting that the simple actof putting one’s feelings into words may possessemotion regulating properties superior to otheremotion regulation strategies (Lieberman et al.,2007; Pennebaker, 1997). For instance, a recentstudy found that verbalizing fear and anxiety duringexposure to fear-inducing stimuli was superior toreappraisal and distraction in reducing skin conduc-tance response in individuals suffering from phobias(Kircanski et al., 2012). Furthermore, the greater useof fear and anxiety words during exposure wascorrelatedwith greater reductions in fear responding.These findings suggest that the act of labeling one’semotional experience in itself attenuates the intensityof that emotion, serving a powerful emotion regula-tion function. For individuals with BPD enmeshed inemotional cascades, the momentary ability to labeland distinguish one’s emotional experience mayreduce emotional intensity and help obviate theperceived need to engagemaladaptive strategies suchas NSSI to manage these intense emotions. Futureresearch should test this prediction by examining therelationship between emotion-labeling interventionsand NSSI risk in BPD.The present findings are also consistent with
research suggesting that emotion differentiation isassociated with adaptive emotion regulation innonclinical populations (Barrett et al., 2001; Kang& Shaver, 2004) and with recent clinical researchdemonstrating negative emotion differentiationdeficits in major depressive disorder (Demiralp etal., 2012). Our study unites these two lines ofinquiry by demonstrating the beneficial effects ofnegative emotion differentiation against NSSI inBPD, a clinical population characterized by mal-adaptive responses to negative emotions. Given theprominence of emotion disturbances in manypsychological disorders (Barlow, Allen, & Choate,
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2004; Kring, 2008; Watson, 2005), as well as thepresence of NSSI in other clinical disorders andpopulations (e.g., adolescents, military recruits;Hilt, Nock, Lloyd-Richardson, & Prinstein, 2008;Klonsky, Oltmanns, & Turkheimer, 2003), in-vestigating the salutary effect of emotion differen-tiation in other clinical disorders represents animportant area for future investigation. Onepossibility may be that emotion differentiationdeficits represent an index of severity for clinicaldisorders characterized by intense negative emo-tions. Future research should investigate thispossibility by exploring emotion differentiation indiverse psychopathologies.In addition, our findings contribute to a growing
body of work suggesting that emotion differentia-tion provides specific resiliency against maladaptivebehavioral outcomes in emotionally at-risk individ-uals (e.g., binge drinking, aggression; Kashdan etal., 2010; Pond et al., 2012). Precisely how emotiondifferentiation protects against dysregulated behav-iors deserves further attention. For example, is theeffect due to one’s specificity in the use of language,or might it be attributed to a more general ability tomake fine-grained distinctions in one’s experience?Although definitive answers to this question remainelusive, evidence suggests that as an individual’slinguistic ability to describe emotional experiencesevolves from broad categories (e.g., good vs. bad) tomore discrete entities across development, so toodoes self-regulation ability (Widen & Russell,2010). Thus, the precise nature of the languageused to describe one’s emotional experiences mayprovide critical knowledge needed to help ensureeffective behavioral responses to those experiences.Another possibility may be that emotion differen-
tiation provides a type of “psychological distance”from “hot” emotions that allows the individual tomore adaptively reflect on emotional experiences,thereby decreasing rumination and negative affectintensity (Metcalfe & Mischel, 1999). This hypoth-esis is supported by research conducted in nonclinicaland clinically depressed populations, which demon-strated that focusing on the reasons underlying anegative emotional experience—as opposed to thedetails of what one has experienced—reducesrumination and negative affect intensity when in-dividuals also reflect on their experience from athird-person perspective (Kross et al., 2005, 2012).Using this strategy, individuals are able to processnegative emotional experiences without becomingoverwhelmed by them. It is possible that emotiondifferentiation may interrupt emotional cascades viaa similar distancing mechanism that allows forprocessing of negative emotional experiences with-out further increasing distress, thereby reducing the
likelihood of engaging maladaptive behaviors toshort-circuit one’s distress.Finally, the current study enriches the growing
literature on emotion-focused treatments by pro-viding support for the assumption that accurateemotion identification and labeling may underliemore adaptive self-regulation. Several approaches(e.g., dialectical behavior therapy, schema therapy,emotionally focused therapy) call for accurateobservation and labeling of emotional states as thefirst step toward effective regulation (Greenberg &Johnson, 1988; Linehan, 1993; Young, Klosko, &Weishaar, 2003). This guiding assumption, whileaccepted andwidely implemented, has been difficultto investigate empirically. The current study pro-vides initial empirical support for this widespreadbelief and practice in the treatment of BPD.There are several notable limitations to this study.
Given the well-documented challenges in conduct-ing research on BPD in general, addressing sensitivetopics such as NSSI in particular, and using lengthyexperience-sampling protocols (Prinstein, 2008;Sung et al., 2003), it is not surprising that thesample size was relatively small. However, oursample was comparable in size to similar experience-sampling studies on BPD (Russell, Moskowitz,Zuroff, Sookman, & Paris, 2007; Trull et al., 2008;Wolff, Stiglmayr, Bretz, Lammers, & Auckenthaler,2007; see Nica & Links, 2009, for review), and—more important—adequate to detect the a prioriinteraction. Of course, given the clinical and theoret-ical relevance of the findings, it will be important toreplicate these results in future studies.Another limitation was the lack of a clinical
control condition in the present study. Futureresearch should compare emotion differentiationin diverse clinical populations in order to moreprecisely understand the correlates and functions ofthis construct in psychopathology. Moreover,participants with BPD who did not endorsehistories of NSSI were excluded from the finalstudy sample. Thus, the population to which thefindings may be generalized remains restricted tothe subset of individuals with BPD who report NSSIhistories, rather than to individuals diagnosed withBPD more broadly.Participants in this study reported low rates of
NSSI acts and urges, consistent with the under-standing of NSSI as a low base-rate behavior(Meehl & Rosen, 1955). We attempted to addressthis challenge in advance by including only thoseBPD participants who reported a lifetime history ofNSSI during the diagnostic interview (e.g., on BPDcriterion 5) or on a self-report measure of NSSI(ISAS), thereby theoretically increasing the chanceof observing NSSI over the three-week diary period.
538 zak i e t al .
Despite this effort, the rate of reported NSSI acts wasstill low, necessitating the combination of NSSI actsand urges into a single self-injury variable. Conse-quently, this study does not address the link betweennegative emotion differentiation and actual self-injury. The low rate of NSSI may reflect the narrowunselected time period across which this study wasconducted (i.e., three weeks). Alternatively, the act ofdaily self-monitoring in itself may have influencedthe reported rate of NSSI acts and urges. Finally, itremains possible that, given the demands of the studyprotocol, individuals with BPD who were undergo-ing particularly stressful periods or who were moreseverely impaired never enrolled.Despite these limitations, the current study
deepens the understanding of emotion processesand NSSI in BPD. By extending basic research onemotion differentiation into the clinical literature,this study builds on growing evidence for theprotective effect of emotion differentiation, demon-strating that emotion differentiation buffers againstNSSI in ruminating individuals with BPD whoreport histories of NSSI. Moreover, the resultsprovide empirical support for mainstream clinicaltheories of BPD suggesting that emotion identifica-tion and labeling are associated with more adaptiveregulatory strategies. These findings have implica-tions for the understanding and treatment of BPDand potentially for other emotional disorders andpopulations, in which significant behavioral dysre-gulation is observed. We hope this research inspiresclinical investigators to further examine emotiondifferentiation and its relation to emotion regula-tion in diverse psychopathologies.
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