EABCT Geneve - Oral Presentation: Rumination and Behaviour Dysregulation in BPD - by Francesca Martino

1. Rumination and Behaviour Dysregulation
in 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

2. 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.

3. 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

4. Emotional Cascade Model (ECM)
Selby, Anestis et al. 2008, 2009
Positive feedback loop
EMOTIONAL Vicious cycle
EMOTIONAL
SENSITIVITY RUMINATION
STIMULI
SHAME
GUILT ET.
Shame and guilt DYSREGULATED Reduce emotionality
Perpetuate the cycle BEHAVIOUR and reinforce the cycle

5. 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)

6. 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

7. 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 volunteers
2. Verify that Anger Rumination mediates the relationship between Emotional
Dysregulation and Aggressive Behaviour

8. 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

9. 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]

10. 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

11. Results: Correlational Analysis
Because of small size of clinical sub-samples we merged BPD with OPD
Final clinical sample (CS) is composed of 49 patients with PDs
 Analysis showed significant correlations between all measures in the clinical
sample (Ranging from .32 to .55)
 Analysis showed significant correlations between all measures in healthy
volunteers (Ranging from .47 to .63)

12. Results: Prediction Analysis
Clinical
Sample
R2 = .42**
.55**
Emotional
Aggression
Dysregulation
Healthy Volunteers
R2 = .23**
.39**
Emotional
Aggression
Dysregulation

13. Results: Mediational Analysis
Clinical Sample
R2 = .33** Anger 1.43*
0.09 ** Rumination *
Emotional
Aggression
Dysregulation
.11
Healthy
Volunteers: Anger
R2 = .41** 0.22 ** Rumination 1.27 **
Emotional
Aggression
Dysregulation
.10

14. 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

15. 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

16. 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)

17. Thank you for your partecipation
Francesca Martino
Cognitive Psychologist
Cognitive Psychotherapy School Studi Cognitivi, Modena, Italy
Institute of Psychiatry, Bologna University, Italy
Email contact: francesca.martino5@unibo.it