Cognitive Processing and Emotional Regulation in ... - MedIND

OCTOBER 2012

DELHI PSYCHIATRY JOURNAL Vol. 15 No.2

Review Article

Cognitive Processing and Emotional Regulation in Borderline Personality Disorder Vandita Sharma, Tej Bahadur Singh Department of Psychology, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, Delhi-110095

Introduction Borderline personality disorder (BPD) is estimated to occur in 1% to 2% of the general population.1 The current Diagnostic and Statistical Manual of Mental Disorders, 4th ed.2 characterizes BPD as a pervasive, longstanding, and inflexible pattern of instability in affect, self-image, and interpersonal relationships. Patients with BPD often experience profound impairment in general functioning, marked impulsivity, and high levels of anger and hostility.3 Further, individuals with BPD are at increased risk for self-injurious and suicidal behaviors, with an estimated suicide completion rate of up to 10%.4 Thus, BPD is a chronic, debilitating, and life-threatening disorder that represents a serious clinical and public health concern. Several studies show that individuals with BPD tend to view others as malevolent5-7 and to describe themselves as unlovable, inherently evil or bad, dependent, and helpless.8-11 These difficulties are thought to arise from impair ed and maladaptive mental representations of self and others, or cognitiveaffective schemata,12-14 which contain expectations about social situations that structure how one thinks and feels about oneself and others.15 In times of acute stress, cognitive processes may be affected, resulting in brief episodes of paranoia, delusional thinking, and a spectrum of dissociative experiences (e.g., depersonalization, derealization, amnesia). Relational crises are common, they often injure themselves, and they often engage in substance abuse, usually as a form of self-medication. Object relation theorists have further elaborated on this, and introduced “borderline” as a personality organization related to a hypothesized fixation in the separation–individuation developmental phase

of the child. A borderline organization is described as an immature personality, characterized by identity diffusion and the use of primitive defenses such as splitting and projective identification but a largely intact reality testing.16 The Cognitive Perspective The cognitive style of borderlines may be viewed as the direct result of the split architecture of their object-representations. When relationships are threatened, however, their level of ego functioning begins to slip. Secondary process thinking, based on the reality principle, begins to give way to primary process thinking, based on wishes, fantasies, and direct drive discharge. The ability to weigh facts, to consider situations from the viewpoints of everyone involved, to develop a plan adaptive in both the short term and long term- metacognitive monitoring is usually impaired in patients of BPD. Metacognitive monitoring17 refers to the ability to observe oneself while speaking and to detect errors in reasoning or inconsistencies in one’s narrative—to think about thinking. Metacognitive knowledge refers to the recognition of an appearance-reality distinction that things may not be as they appear and that appearances are never certain12. It also refers to an awareness that the same things might appear differently to different persons and that our thoughts vary from day to day about the same topic. At this level, splitting and its associated mechanisms, such as projective identification, dominate the clinical picture. Beck et al18 hypothesized that a large number of assumptions common to other personality disorders are active in BPD. Pretzer 19 further

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hypothesized that three key assumptions are central in BPD: “The world is dangerous and malevolent,” “I am powerless and vulnerable,” and “I am inherently unacceptable.” The first assumption in combination with the second is hypothesized to lead to high levels of vigilance and interpersonal distrust. In addition to hypervigilance, two other cognitive characteristics are assumed to be central to BPD: dichotomous thinking and a weak sense of identity (i.e., a poorly articulated self-schema). Dichotomous thinking contributes to the emotional turmoil and extreme decisions of these patients. Pretzer regards dichotomous thinking, the chronic use of mutually exclusive categories, as the central cognitive distortion of the borderline personality. By construing the world in either/or terms, borderlines are forced into extreme interpretations that disqualify adaptive responses proportional to situational needs; there are few intermediate responses, few shades of gray, and few qualitatively complex appraisals following a period of detached deliberation. Opinions of self, world, and future tend to be either completely positive or completely negative. Young et al20 hypothesized that four schema modes are central to BPD: the abandoned child mode; the angry/impulsive child mode; the punitive parent mode, and the detached protector mode. The abandoned child mode denotes the desperate state the patient may be in related to (threatened) abandonment and abuse the patient has experienced as a child. Typical core beliefs are that other people are malevolent, cannot be trusted, and will abandon or punish you, especially when you become intimate with them. Other core beliefs are: “My emotional pain will never stop,” “I will always be alone,” and “There will be nobody who cares for me.” The angry/impulsive child mode denotes a stage of childish rage or self-gratifying impulsiveness that is in the long run damaging for the patient and his or her relationships. Patients with BPD typically avoid the experience and expression of anger, however, the tension of suppressed anger may build up and suddenly be expressed in a relatively uncontrolled way. The punitive parent mode is characterised by impulsive, immediate need-gratifying behaviours. Underlying beliefs are: “My basic rights are 280

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deprived”; “Other people are evil and mean”; “I have to fight, or just take what I need, to survive.” The detached protector mode is a sort of protective style the patient may have developed as a child to survive in a dangerous world. This mode is hypothesized to serve to protect the patient from attachment (because attachments will be followed by pain, abandonment, punishment, or abuse), emotional experience, self-assertiveness, and development, as each of these signals potential pain and activation of the punitive mode. Often the patient uses a bulk of strategies to maintain this mode, including cognitive avoidance of feeling and thinking; not talking; avoidance of other people and activities; sleeping, developing, and complaining about somatic discomforts; use of drugs and alcohol; and even (para)suicide. The level of borderline cognition is also dependent on the degree of structure in the external environment. Borderlines look healthier on structured tests, such as pencil-and-paper personality tests, but less healthy on projective instruments, such as the Rorschach Inkblot Test or Thematic Apperception Test, where the subject invents stories based on pictures. In any projective situation, subjects appeal to their own internal structure to bring order to the interpretation of an ambiguous stimulus. Because borderlines have little internal structure to bring to unscripted situations, however, they can only project fluidity onto ambiguity. In effect, borderlines borrow the structure of the environment to organize themselves. Without such structure, they can quickly regress to more primitive ego states. Studies that have examined the Rorschach protocols of BPD patients21-24 found deviant thought and communication patterns, an inability to maintain or shift cognitive set, and odd reasoning. Exner25 described the BPD cognitive style on the Rorschach as underincorporative and indicative of an “immature and or inadequate organizational structure”. The identity diffusion of borderlines suggests that they are particularly vulnerable to intrusive thoughts and images, including flashbacks and nightmares. Borderlines do seem to associate from one unpleasant thought to the next, evoking a succession of intense affective states connected only


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by the private experiences of the person. For example, a new acquaintance might be looked at admiringly until it is discovered that he or she has a particular mannerism that resembles someone in the past with whom the borderline has unresolved issues. Awareness of this similarity may bring to mind morbid memories so intense that the acquaintance becomes a lightning rod for the negative emotions that he or she has unwittingly evoked. BPD patients are vulnerable to a disorganization of cognitive processing in the form of brief, acute paranoid and other psychotic states and a more generalized inability to problem solve. This usually occurs when attachment to significant others is seriously threatened through abandonment or attack. These states represent a breakdown in the processing of information and in the patient’s attempt to restore meaning. In a paranoid state, the BPD patient can become convinced that a significant other is out to harm her or him and will mobilize action to protect the self. Around loss or abandonment or in the midst of a major depression, the BPD patient may hear voices of a loved one or experience other psychotic-like phenomena. Emotional Dysregulation Linehan 26 has proposed that emotional dysregulation is the core problem for BPD patients and that its impact extends beyond the sphere of affect to permeate all aspects of the individual’s life. BPD patients have not fully developed the ability either to differentiate emotions or to experience multiple emotions as part of a single emotional reaction. BPD patients frequently misread interpersonal situations and overreact or underreact, depending on this misinterpretation.27 These swings from hyperarousal to underarousal are related to a misinterpretation of emotional signals, which in turn interferes with planning adaptive responses. Emotional dysregulation is typically expressed through affective instability, periodic states of “emptiness,” emotional numbing, aversive tension, and intense anger. It is difficult to describe “emptiness,” but we liken it to a feeling of the presence of absence. It is accompanied by an awareness that something is missing. When it persists, the patient becomes increasingly

dysphoric. The dysphoria can trigger a variety of potentially self-damaging behaviors that represent an attempt to dispel it and restore more normal feeling states. BPD patients also have particular difficulty with the modulation of anger. Borderline patients experienced enormous frustration of need and helplessness throughout childhood. Their poor emotional vocabulary further contributes to high levels of inarticulate frustration. This frustration, in combination with their underlying contradictory temperamental dispositions, creates a substrate of dysphoria and disgruntlement that can easily turn into anger when fueled by cognitive distortions and misinterpretations of interpersonal situations.28 Case Report Ms. S, a 37 yr old Hindu housewife, married since 21 yrs, educated till 10th grade, belonging to MSES presented with complaints of sadness of mood, with frequent boredom, excessive unprovoked anger outburst, irritability, crying spells, excessive episodes of disputes and aggressive outbursts with family members, and occasional suicidal threats since 21 years. In the past 6 years the symptoms had worsened and the patient frequently threatened suicide and there were multiple episodes of head banging, and, cutting wrists and legs. In the last 3 yrs, she had also started an excessive overuse of Alprazolam 0.5 mg. During the initial years of her marriage, the patient developed intense emotional ties with her husband, idolizing him, and treating him as a worship figure. She would get restless and react with excessive anxiety if her husband went on work related outstation trips, would write innumerable letters to the husband asking him to return and stop doing her routine household chores as a result of restless and discomfort caused by the husband’s absence. When she had an altercation with her husband, the patient would respond with extreme anger characterised by shouting and howling behaviour, throwing household articles, with occasional attempts to hit the husband, accusing herself to be the sole cause of any problem in the marriage and threatening to leave. Occasionally, she would also threaten to take poison or hang herself but never did so. The patient would doubt and comment upon the husband’s character if she saw him talking to any female,


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check his diaries, files, and phone for contacts with any female, would also accuse him of having an affair if she saw him talking to a neighbourhood woman and would complain that she was unlikeable, that she deserved to be deceived, and that she did not deserve her husband’s love, so it would be a right thing to leave her. The patient responded with excessive anger if her children threw any tantrums, often hitting them and scaring them. 6 years back the patient discovered that her husband had an illicit relationship of 2 yrs with another woman and reacted with extreme anger, hitting her husband, getting aggressive and throwing household articles. Following the episode, the patient started feeling excessively sad and would cry excessively, feel confused and restless, that her life had lost all meaning, and that there was nothing to look forward to. She would also threaten to her husband that she will jump off from the roof, hang her, would lay on a railway track, or drink phenyl but never made any such attempts. When the husband tried to convince her that he had terminated the affair and had no contact with the woman, the patient would not believe him, and would verbally abuse him and hit him, often in front of her children. After altercations with her husband, the patient would periodically enter the bathroom and cut her wrists and legs with a blade. She reported that these acts were done impulsively, when she felt she had completely lost control over herself and did not know what she was doing. She also reported that she would feel “light and better” after these acts. On coming out of the bathroom, she would hold the wounded areas in such a position for the husband to see, or would cry in pain, trying to grab the husband’s attention. The patient would also start hitting her head against the walls following disputes with her husband. These acts of deliberately causing self-injury always occurred after an altercation and were never done when the patient was alone. She was taken to a private practitioner in 2007 where she was prescribed alprax as a part of the treatment. The patient gradually increased the drug use over a period of time and eventually started taking the medicine after every altercation with her husband. She reported that the drug also helped her get rid of the “emotional pain” caused. Gradually, the patient started increasing the dosage/ day in order to have the same effect, increasing the intake up to 5 pills 282

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in a day. Her attempts to reduce or stop the drug consumption were mostly unsuccessful. However, the patient did not report any symptoms of anxiety, somatic symptoms, distress or impaired functioning on days when she did not take the drug. Personal and Family History The patient was born full term normal delivery with no significant developmental history. When she turned a year old, her younger brother was born. When she was 2 yrs old, her mother died. Patient was being breast fed during that period. She became irritable and would cry easily, there was an increase in her temper tantrums; she would easily get angry and wake up during the nights and also started falling ill frequently. In the next 6 months, her younger brother also died of acute pneumonia. Soon after, her father got remarried. The patient reacted with fear and withdrawal behaviours towards her step mother and bonded with her only after the birth of her step sister. The patient had five step-siblings and bonded well with them. Patient started schooling at the age of 5 years in an all-girls school till 10th grade. She was an average achiever throughout school and would not like participating much in extra-curricular activities. In school she reportedly developed feelings of jealousy towards her batch mates and had a limited peer group, with short lasting friendships. Soon after getting out from school the patient got married at the age of 16 yrs. She stayed in a joint family set-up during the first 3 months of her marriage after which she shifted into a nuclear setup due to frequent altercations with her mother-in-law. Patient currently has 3 childrenelder daughter and 2 sons. She perceives her children as disobeying, and disrespecting, and considers herself under-valued, and unwanted by family members. Her children are closer and more comfortable in communicating with their father. The patient’s daughter perceives the patient as rejecting, irritable, angry, emotionally unavailable, misinterpreting interactions, and unable to understand her emotional needs. Her elder son perceives the patient as unpredictable, emotionally reactive most of the times, responding with aggression and anger to his emotional needs. Her husband and daughter are cooperative towards the patient in view of her illness, while her sons are indifferent.


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Psychometric test findings On objective assessment, analysis of personality test results revealed that the patient was ambiverted, with average intellectual functioning, low ego strength, high superego controls, suspicious, hard to fool, not easily trusting, apprehensive, guilt prone, reactive, vigilant, apprehensive and easily tensed and frustrated. She had significantly high conflicts in her family unit, heterosexual relationship, own ability, and future. She was found to be using an escape-avoidance coping style in dealing with her problems. Patient was using a preoccupied and fearful attachment style in her current important close relationships. Scores obtained on BDI revealed that the patient was currently suffering from moderate level of depression. On projective assessment, stories on TAT revolved around the central theme of triangular oedipal conflict, where the hero faces crisis, has a low problem solving ability, leading to negative outcome. T he main hero was perceived as inadequate, lacking control over emotions, suspicious of others, lonely, aggressive, angry, acting out impulsively ,with a low ego strength, and grandiose fantasies of fame in narcissist way. He was also found to engage in wish fulfillment fantasy, had intense but short lived IPR, was frequently rejected by others, and experienced pure affect states (love, care, hate, aggression). Commonly held beliefs were: ‘one cannot trust faithfulness of loved one’, ‘if I love and trust, I will be deceived’. The environment was perceived as rejecting, overpowering, uncaring, negative and threatening, and deceiving. Contemporary figures were seen as rejecting, unavailable, unreliable, and aggression (real or imagined) was dir ected ar ound contemporary male figures. The main fears and anxieties revolved around physical harm, abandonment, being r epulsed and rebuked, rejection, loneliness, deprivation, loss of love, and punishment. The main defense mechanisms used were splitting, denial, escape into fantasy, projection, reaction formation, and rationalization. Rorschach protocols revealed that the patient was striving to accomplish beyond her functional capacity, and failures were leading to frustration. She was found to be using an under-incorporate form of scanning activity, scanning the environment

hastily, haphazardly, neglecting critical cues leading to faulty translation of cues, giving less conventional and more individualistic responses to her environment. She was inclined to merge feelings with thinking, and was found to have fixed, inflexible ideational sets. She was found to be experiencing chronic stimulus overload, with more internal demands than she can respond to, her decisions and behavior were not well thought through, she had a less control capacity, and was vulnerable for losing control and disorganization under stress. She was found to be more prone to display her feelings openly, and was very attracted to emotional stimuli, displaying a strong interest in emotions. Chronic failure had led to an intense emotional impact. She was found to be impulsive, less mature, and experiencing confused emotional states. There were serious lapses in modulation of affect resulting in inappropriate, and maladaptive behavior. The patient had a negative self worth, and was found to regard self less favorably compared to others, serious conflict in self image and self value was found. She was also found to be lacking self awareness, with a more imagined perception of self. She acknowledged and expressed needs of closeness in ways dissimilar than others, was overly concerned with creating and maintaining emotional ties with others, and was more likely to be socially isolated. She was generally found to have difficulty in creating and sustaining smooth meaningful interpersonal relations and would often find herself void of rewarding relationships. Discussion Borderline Personality disorder has been extensively investigated from various perspectives. Here we have made an attempt to formulate a case of borderline personality disorder from a cognitivedevelopmental model.29 Cognitive Dysfunction Ms S’s problems in cognitive processing have been clearly evident in the history as well as assessment findings. She exhibited black-and-white thinking, especially in relationship to others, who were perceived as all good or all bad and making overgeneralized interpretations of her altercations with her husband and in-laws. Test findings also revealed that she would often experience random,


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disconnected patterns of thinking and would intermingle feelings with thinking during problem solving. She was also using an under-incorporative style of scanning her environment further resulting in ignoring critical bits of information leading to faulty cognitive processing and misinterpretations. She has rigid, fixed, inflexible ideational sets making the picture more complicated. During sessions, the patient revealed the following maladaptive schemas and cognitions: “I am unlovable”, “If I love and trust someone, I will be deceived”, “People I am close to are unfaithful”, “People take advantage of me” “I cannot live alone, I need someone to be around”, ‘If I feel bad,I will lose control over myself”. Her paranoia was expressed throughout her life as extreme sensitivity to insult and suspiciousness towards husband, checking his personal belongings right from early days of her marriage. She took offense easily and often. She was also reportedly jealous of many of her batchmates during all her years of schooling. On employing Young’s schema modes 20 we observed that patient has been frequently exhibiting the abandoned child mode where historically, the patient may have suffered abandonment on the death of her mother which occurred during the separation-individuation stage of development thereby resulting in faulty object representations; followed by the death of a younger sibling within a short span of time. These feelings of abandonment

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and resulting fears continued till early years of marriage where the patient would complain of boredom and decreased functioning when her husband would go to work related trips and would make frantic attempts to call him back. Results from projective assessment also revealed that the main fears and anxieties of the patient revolved around physical harm, abandonment, being repulsed and rebuked, rejection, loneliness, deprivation, loss of love, and punishment. She is also found to be exhibiting the angry/impulsive child mode where she has been acting impulsively, and immaturely with often unexplained aggressive and violent outbursts towards husband and in-laws. This is further elaborated in the assessment findings where she is found to be lacking control over emotions, aggressive, acting out and angry, having a less control capacity, and high vulnerability for losing control and disorganization under stress. The detached protector mode is also observed in the patient’s overuse of benzodiazepines in an attempt to avoid emotional pain leading to decreased interactions with family members, and excessive sleepiness. Emotional dysregulation Ms. S has been found to experience states of emotional labiality with periods ranging from emotional dullness or over-emotionalism and outbursts of anger. History reveals that she has been experiencing a pervasive and debilitating anxiety


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when her relationships were disrupted. She has been experiencing pure affect states (love, care, hate, aggression) and is found to be more prone to display her feelings openly, and was very attracted to emotional stimuli, displaying a strong interest in emotions. Assessment findings reveal serious lapses in modulation of affect resulting in inappropriate and maladaptive behavior. She has also been overly concerned with creating and maintaining emotional ties with others. In the following section we attempt to present a formulation of this case based on the cognitive developmental model: See Figure. Conclusion Treating patients with borderline personality disorder can be at the same time challenging and fulfilling. A well-considered, developmentally based formulation that attends to the full range of factors implicated in the etiology and maintenance of the disorder is important if therapists are to help these patients overcome the long-standing and very debilitating emotional and behavioral patterns that characterize this disorder. Developing social supports and understanding the ways in which adverse early experiences may have served as templates or models for current relationships become an important focus of treatment. Cognitivedevelopmental models are quite new and sit at the interface of the cognitive behaviour therapy and developmental psychopathology literatures. References 1. Torgersen S, Kringlen E, Cramer V. The Prevalence of Personality Disorders in a Community Sample. Arch Gen Psychiatry 2001; 58 : 590-596. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Washington, DC: Author 2000. 3. Skodol AE, Gunderson JG, McGlashan TH, et al. Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive– compulsive personality disorder. Am J Psychiatry 2002; 159 : 276-283. 4. Oldham JM, Gabbard GO, Goin MK, Gunderson J, Soloff P, Spiegel D, et al. Practice guideline for the treatment of patients with borderline personality disorder. Am J

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24. Sugarman A: The borderline personality organization as manifested on psychological tests, in Borderline Phenomena and the Rorschach Test. Edited by Kwawer J, Lerner H, Lerner D, et al. New York, International Universities Press, 1980; pp 39–57. 25. Exner J. The Rorschach: A comprehensive system: Vol. 1. Basic foundations (2nd ed.). New York: John Wiley and Sons 1986. 26. Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford 1993. 27. Clarkin JF, Foelsch PA, Levy KN, Hull JW, Delaney JC, Kernberg OF. The development of a psychodynamic treatment for patients with borderline personality disorder: a preliminary study of behavioral change. J Pers Dis 2001; 15(6) : pp. 487-495. 28. Harris and D. Olson (Eds.) Developing theories of mind. New York: Cambridge University Press. 29. Reinecke M, and Ehrenreich J. A CognitiveDevelopmental model of Borderline Personality Disorder. Behav Cogn Psychother 2001; 29 : 129–141.
