Personality and Mental Health

(2012)
Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI 10.1002/pmh.1204

Difficulties with emotion regulation mediate

the relationship between borderline
personality disorder symptom severity and
interpersonal problems

NATHANIEL R. HERR1, M. ZACHARY ROSENTHAL1, PAUL J. GEIGER1 AND

KAREN ERIKSON2, 1Duke University Medical Center, Durham, NC, USA; 2University of Nevada,
Reno, NV, USA

ABSTRACT
Problems with interpersonal functioning and difficulties with emotion regulation are core characteristics of borderline
personality disorder (BPD). Little is known, however, about the interrelationship between these areas of dysfunction
in accounting for BPD symptom severity. The present study examines a model of the relationship between difficulties
with emotion regulation and interpersonal dysfunction in a community sample of adults (n = 124) with the full
range of BPD symptoms. Results showed that difficulties with emotion regulation fully mediated the relationship
between BPD symptom severity and interpersonal dysfunction. An alternative model indicated that interpersonal
problems partially mediated the relationship between difficulties with emotion regulation and BPD symptom severity.
These findings support existing theories of BPD, which propose that difficulties with emotion regulation may account
for the types of interpersonal problems experienced by individuals with BPD and suggest further examination of
the possibility that interpersonal dysfunction may worsen these individuals’ difficulties with emotion regulation.
Copyright © 2012 John Wiley & Sons, Ltd.

Borderline personality disorder (BPD) is charac-
terized by the chronic presence of a heterogeneous
constellation of symptoms that include emotional
(e.g. affective instability), cognitive (e.g. paranoia
or dissociation when stressed), behavioural
(e.g. self-injurious behaviour) and interpersonal
(e.g. idealization and devaluation of others) symp-
toms (American Psychiatric Association, 2000).
Despite the diversity in symptom presentations
found among individuals with BPD, factor analytic
and family aggregation studies have shown that
BPD symptoms can be organized around several
key latent variables, including emotional dysregula-
tion, behavioural dyscontrol and interpersonal
dysfunction (e.g. Sanislow, Grilo, & McGlashan,
2000; Silverman et al., 1991). Although recent
research has begun to examine the neurobiological
and behavioural process that may underlie the
aetiology and maintenance of these core BPD
factors (e.g. emotional dysregulation, Donegan
et al., 2003; and impulsivity, Siever, Torgersen,
Gunderson, Livesley, & Kendler, 2002), it is
not yet clear how these core factors relate to and
influence each other in the expression of BPD

Copyright © 2012 John Wiley & Sons, Ltd. (2012)

DOI: 10.1002/pmh
Herr et al.
symptoms. To address this gap in the empirical
literature, in the present study, we examined
the relationships among problems with emotion
regulation, interpersonal dysfunction and symp-
toms of BPD.
BPD and emotion regulation
Emotion regulation is a multi-faceted construct
that includes both antecedent-focused (changing
the environment) and response-focused (changing
emotional expression) modulation of emotional
experience (Gross & Thompson, 2007). Skilled
emotion regulation does not imply the absence
of negative emotions but rather implies that an
individual can maintain goal-directed behaviour
even in the presence of intense, negative emotional
experiences (Fruzzetti, Crook, Erikson, Lee, &
Worrall, 2009). Emotion dysregulation, in turn,
includes but does not equate with experiencing
strong negative emotions. Although there is no
consensus definition of emotion dysregulation, one
recently proposed conceptualization of this multi-
dimensional construct includes the following:
(1) lack of awareness, understanding and acceptance
of emotions; (2) lack of access to adaptive strategies
for modulating the intensity and/or duration of the
emotional response; (3) unwillingness to experi-
ence emotional distress as a part of pursuing desired
goals; (4) difficulty controlling impulsive beha-
viours when distressed; and (5) inability to engage
in goal-directed behaviours when distressed (Gratz
& Roemer, 2004).
Influential contemporary conceptualizations of
BPD have suggested that problems with emotional
dysregulation are central to the disorder (Linehan,
1993; Paris, 1994; Siever et al., 2002). Self-report
studies examining emotion dysregulation in BPD
have used both cross-sectional and prospective
measures of emotion regulation constructs such as
negative affective intensity, affective instability and
emotional reactivity (see Rosenthal et al., 2008, for
a review). Individuals with BPD report significantly
higher baseline levels of negative affect compared
with non-clinical controls and individuals with
Copyright © 2012 John Wiley & Sons, Ltd.
other personality disorders (Henry et al., 2001;
Koenigsberg et al., 2002; Levine, Marziali, &
Hood, 1997). Negative affect intensity is associ-
ated with higher BPD features (Cheavens et al.,
2005) and diagnostic symptoms (Rosenthal,
Cheavens, Lejuez, & Lynch, 2005; Yen, Zlotnick,
& Costello, 2002). In addition, studies using
experience sampling methodologies have found
that individuals with BPD report greater intensity
of negative emotions and greater fluctuations in
affective states compared with healthy controls and
individuals with other psychiatric disorders (Cowdry,
Gardner, O’Leary, Leibenluft, & Rubinow, 1991;
Ebner-Priemer et al., 2007; Stein, 1996; Stiglmayr
et al., 2005). There is evidence that experiential
avoidance (i.e. the lack of willingness to experi-
ence negative emotions) mediates the relationships
between anxiety sensitivity and BPD symptoms
(Gratz, Tull, & Gunderson, 2008), and experiential
avoidance has been found experimentally to be
greater in a group of outpatients with BPD com-
pared with outpatients with no personality disorders
(Gratz, Rosenthal, Tull, Lejuez, & Gunderson,
2006). Likewise, there is growing empirical evi-
dence that self-injury, a behaviour that is charac-
teristic of individuals with BPD, functions as a
problematic strategy to avoid intense emotional
experiences (Chapman, Gratz, & Brown, 2006).
A common self-report tool used to measure
specific problems with emotion regulation in BPD
is the Difficulties with Emotion Regulation Scale
(DERS; Gratz & Roemer, 2004), which assesses
deficits in six emotion regulation skills, including
the following: lack of emotional awareness or clar-
ity, unwillingness to experience and accept negative
emotions, difficulty controlling impulsive beha-
viours when distressed, difficulty accomplishing
goals when emotionally distressed and perceived
lack of access to strategies needed to regulate
emotions when distressed. Findings suggest that
problems with emotion regulation as measured
by the DERS are related to higher levels of BPD
features and symptoms both in undergraduate
and clinical samples (Bornovalova et al., 2008;
Chapman, Leung, & Lynch, 2008; Glenn &
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DOI: 10.1002/pmh

Klonsky, 2009). In addition, Kuo and Linehan
(2009) reported that DERS scores were significantly
higher among individuals with BPD compared with
healthy controls and a clinical control group com-
posed of participants with social anxiety disorder.
Across all of these studies, there is a great deal
of evidence that self-reported emotional intensity,
lability, experiential avoidance and emotion regula-
tion skill deficits are associated with higher BPD
symptom severity and may differentiate individuals
with BPD from other samples. As a next step, it is
important to investigate whether, as hypothesized
by Linehan (1993), greater difficulties with emotion
regulation may account for other BPD-related
phenomena. Although the diagnostic symptoms
of BPD are topographically different, it is possible
that emotional dysregulation may functionally
link all of the BPD symptoms in that each symp-
tom is either a maladaptive strategy for regulating
emotions (e.g. self-injurious behaviour; Chapman
et al., 2006) or a natural consequence of dysregu-
lated emotions. In particular, it is possible that
interpersonal dysfunction, another central char-
acteristic of BPD, falls into this latter category.
BDP and interpersonal functioning
Studies examining the interpersonal functioning
of individuals with BPD have shown that inter-
personal dysfunction may be one of the key
features that differentiates BPD from other psychi-
atric disorders (Nurnberg, Hurt, Feldman, & Suh,
1988; Modestin, 1987; Skodol et al., 2002). In
addition, longitudinal studies suggest that impair-
ment in social functioning in BPD is stable across
time (Skodol et al., 2005; Zanarini, Frankenburg,
Hennen, Reich, & Silk, 2005). Interpersonal
dysfunction in BPD has also been examined
experimentally, with Dougherty, Bjork, Huckabee,
Moeller, and Swann (1999) showing that indivi-
duals with BPD responded more aggressively than
normal controls on a competitive computer task,
although the result was no longer significant after
controlling for depressive symptoms. A study using
a different lab-based task found that individuals
Copyright © 2012 John Wiley & Sons, Ltd.
Emotion REG and interpersonal functioning in BPD
with BPD were worse than healthy controls in their
ability to fix a broken cooperative relationship in a
social exchange laboratory task (King-Casas et al.,
2008). Data from this study suggest that, compared
with healthy controls, individuals with BPD may
be less likely to perceive violations of social norms
in interpersonal contexts.
Research using experience sampling methods
also has found evidence of interpersonal problem
in individuals with BPD. Russell, Moskowitz,
Zuroff, Sookman and Paris (2007) asked indivi-
duals with BPD and non-clinical controls to
complete short surveys following any substantive
social interactions for 20 days. They found that
individuals with BPD reported more submissive,
quarrelsome and extreme interpersonal behaviours
than the non-clinical controls. Another study asked
participants to track social interactions for 7 days
using a hand-held computerized social interaction
diary (Stepp, Pilkonis, Yaggi, Morse, & Feske,
2009). Although individuals with BPD reported
a similar amount of social interaction per day
compared with individuals with other personality
disorders and normal controls, they reported inter-
acting with fewer people overall. The individuals
with BPD also reported having more disagreements,
more negative emotional reactions to social interac-
tion and more overall ambivalence with respect to
social interactions. Collectively, these studies use
diverse methods of measurement, which converge
on the conclusion that problems with interpersonal
functioning characterize BPD.
The relationship between emotion regulation and
interpersonal functioning in BPD
Although difficulties with emotion regulation and
interpersonal dysfunction are separate constructs,
it is unlikely that they are orthogonally related. The-
oretical models of BPD posit that poor emotion
regulation leads to problems in interpersonal
relatedness (e.g. Linehan, 1993; Putnam & Silk,
2005), yet few of the interpersonal functioning stud-
ies described previously assessed emotion regulation
difficulties. One that did (Stepp et al., 2009) found
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Herr et al.
more conflictual and emotionally intense day-to-day
social interactions in individuals with BPD, as
compared with those without BPD. Among the
few additional studies that have examined the rela-
tionship between elements of emotion regulation
and interpersonal dysfunction, results have been
mixed. Support for the model that affective instabil-
ity leads to poorer interpersonal functioning was
found in a 2-year follow-up of undergraduates with
BPD features (Bagge et al., 2004). Alternatively,
Koenigsberg and colleagues (2001) found that
affective problems were related to some of the diag-
nostic criteria of BPD (e.g. identity disturbance and
suicidality) but were not related to interpersonal
dysfunction. Although affective instability is one
component of emotional dysregulation, additional
research is needed to help clarify the nature of
the relationship between problems with emotion
regulation and interpersonal dysfunction in BPD.
In sum, recent studies indicate that BPD is char-
acterized by difficulties with emotion regulation and
interpersonal dysfunction. However, research that
examines the extent to which difficulties with emo-
tion regulation account for the relationship between
BPD symptoms and interpersonal dysfunction is
needed. In the present study, we sought to test the
hypothesized model (e.g. Linehan, 1993; Putnam
& Silk, 2005) that emotion regulation difficulties
underlie the relationship between BPD symptoms
and interpersonal dysfunction. Difficulties with
emotion regulation were measured using the DERS
to include aspects of emotion regulation that extend
beyond just intense negative affect. On the basis
of the existing theoretical and empirical research
(e.g. Bagge et al., 2004; Linehan, 1993; Stepp
et al., 2009), we hypothesized that difficulties with
emotion regulation would fully account for the
direct relationship between BPD symptoms and
interpersonal problems. Specific subtypes of inter-
personal functioning (i.e. interpersonal sensitivity,
interpersonal ambivalence, interpersonal aggression,
need for social approval and lack of sociability) were
also examined to determine if difficulties with emo-
tion regulation was more associated with certain
kinds of interpersonal problems. To further explore
Copyright © 2012 John Wiley & Sons, Ltd.
the relationship between emotion regulation and
interpersonal dysfunction, we tested an atheoretical
model specifying that deficits in interpersonal func-
tioning may account for the relationship between
BPD symptoms and difficulties with emotion regu-
lation. On the basis of Linehan’s theoretical model
of emotion regulation, we did not expect this model
would be supported; however, we examined it to
either strengthen arguments for the primary model
or to generate questions for subsequent research.
Despite the limitations of using cross-sectional data,
the present study is the first that we are aware of that
attempted to provide support for either or both of
these models by comparing them in a single sample
of individuals with the full range of BPD symptoms.
Method
Participants
As part of a larger project examining emotional
functioning in BPD, 124 participants were recruited
for the present study through advertisements in a
local free newspaper, on the Duke University
Medical Center website and through outpatient
clinics at Duke University Hospital System. Sepa-
rate recruiting advertisements targeted individuals
with BPD (e.g. ‘Have you ever been diagnosed with
borderline personality disorder?’) and a general
community sample (e.g. ‘Are you interested in a
study about emotion?’). Participants completed a
brief telephone screen to exclude individuals with
current mania and psychosis. Participants who
were between the ages of 18 and 60 years were
eligible and were scheduled to complete the
study within 2 weeks. Participants received $150
compensation for completion of the study.
The final sample included 35 participants
(28.2%) who met full criteria for BPD (see the
following paragraphs for diagnostic interview
description). The sample had a mean age of
36.5 years (standard deviation (SD) = 11.7 years;
range. 18–58 years) and included more women
(n = 83; 66.9%) than men (n = 41; 33.1%). More
than half of the participants were identified as
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African-American (n = 65, 52.4%), whereas
48 (38.1%) were Caucasian, 3 (2.4%) were Asian,
3 were Native American, 2 (1.6%) were Hispanic
and 3 indicated other race/ethnicity. The sample
included 37 (29.8%) participants who were married
or living with a partner, 18 (14.5%) who were in an
intimate relationship and living separately, 18 who
were separated or divorced, 4 (3.2%) who were
widowed, and 44 (35.5%) who were never married.
Most participants (89%) had completed at least
some college. The sample was predominantly
low income, with 47 (37.9%) making less than
$10 000 a year and 51 (41.1%) making between
$10 000 and $40 000 a year.
Measures
Demographics. A self-report measure was used to
obtain demographic and descriptive information,
including age, ethnicity, marital status and annual
household income.
Structured Clinical Interview for DSM-IV, Axis I.
Diagnostic exclusions and current prevalence of
Axis I diagnoses were determined by the Struc-
tured Clinical Interview for DSM-IV, Axis I
(SCID-I; patient version; First, Spitzer, Gibbon,
& Williams, 1995), a measure with demonstrated
reliability (Lobbestael, Leurgans, & Arntz, 2011).
The SCID-I was administered by bachelor and
master’s level assessors trained by the second author
and an expert clinical assessor in the second
author’s lab to reliability. Inter-rater reliability was
assessed by a blind rater randomly rating 20% of
video recorded SCID-I interviews. Kappas ranged
from 0.63 to 1.0, reflecting acceptable inter-rater
reliability.
Structured Clinical Interview for DSM-IV Personality
Disorders, Axis II. The Structured Clinical Inter-
view for DSM-IV Personality Disorders, Axis II
(SCID-II; First, Gibbon, Spitzer, Williams, &
Benjamin, 1997) was used to assess diagnostic
symptoms of personality disorders, including BPD.
Participants first completed the SCID-II Personality
Copyright © 2012 John Wiley & Sons, Ltd.
Emotion REG and interpersonal functioning in BPD
Questionnaire (SCID-II-PQ), a questionnaire with
119 items assessing the presence (yes) or absence
(no) of specific personality disorder symptoms. For
the current study, items endorsed on the SCID-II-
PQ were further evaluated using the standard
SCID-II interview. This two-stage assessment pro-
cess is commonly conducted, with studies suggesting
a low false-negative rate for non-endorsed SCID-II-
PQ items (Jacobsberg, Perry, & Frances, 1995).
Structured Clinical Interview for DSM-IV
Personality Disorders, Axis II interviews were
conducted by bachelor and master’s level assessors
trained by the second author and an expert clinical
assessor in the second author’s lab to reliability.
With the use of digitally videotaped recordings,
approximately 10% of the SCID-II interviews were
randomly re-assessed by a different trained rater.
Inter-rater reliability on total BPD symptoms was
evaluated using intraclass correlation coefficients
(ICCs). The ICC for BPD symptoms was 0.98, indi-
cating excellent reliability. The ICCs for all person-
ality disorders ranged from 0.66 (schizotypal) to 1.0
(histrionic). To obtain a continuous score for BPD
symptom severity that included sub-diagnostic
threshold of symptoms, interviewer-rated symptoms
were summed, which resulted in a possible range of
BPD symptom severity from 0 (no BPD criterion
behaviours present) to 9 (all BPD criterion beha-
viours present beyond threshold). The sample had
a mean score of 2.6 (SD = 3.1) symptoms, and 35
participants (28.2%) met full criteria for a diagnosis
of BPD.
The DERS (Gratz & Roemer, 2004) is a
36-item measure that assesses individuals’ typical
levels of emotion dysregulation across six domains:
non-acceptance of negative emotions, inability
to engage in goal-directed behaviours when dis-
tressed, difficulties controlling impulsive behaviours
when distressed, limited access to emotion regula-
tion strategies perceived as effective, lack of emo-
tional awareness and lack of emotional clarity.
The DERS has been found to have high internal
consistency (a = 0.93), good test–retest reliability
(rI = 0.88, p < 0.01) and adequate construct
and predictive validity (Gratz & Roemer, 2004).
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Herr et al.
Internal consistency in the present sample was
also high (a = 0.89).
Inventory of Interpersonal Problems. The original
Inventory of Interpersonal Problems (IIP; Horowitz,
Rosenberg, Baer, Ureno, & Villasenor, 1988) is a
127-item measure of problems with interpersonal
functioning relevant to samples of individuals with
personality disorders (e.g. Pilkonis, Kim, Proietti,
& Barkham, 1996; Scarpa et al., 1999). Pilkonis
et al. (1996) developed a shortened version (47 items),
which delineated five subscales: (1) inter-
personal sensitivity, (2) interpersonal ambivalence,
(3) interpersonal aggression, (4) need for social
approval and (5) lack of sociability. These sub-
scales were created using factor analysis with items
that were associated with personality disorders and
cross-validated in three separate datasets, demon-
strating adequate ability to distinguish between
individuals with and without personality disorders.
In the present sample, internal consistency was high
for the full scale IIP (a = 0.97), as well as for each
subscale (a’s range from 0.89 to 0.93).
Procedure
This study was approved by the Institutional Review
Board at Duke University Medical Center. All
participants provided written informed consent
prior to participating in the study. Participants
completed diagnostic interviews and self-report
instruments after completing lab tasks that were
part of a larger study of emotion processing. Partici-
pants were given the self-report packet and then
debriefed about the experiment and compensated.
Data analysis
We tested two models in which (1) emotion regula-
tion problems account for the relationship between
BPD symptoms and interpersonal problems and
(2) interpersonal problems account for the relation-
ship between BPD symptoms and emotion regulation
problems. These models were tested using the
mediation procedures outlined by Baron and Kenny
Copyright © 2012 John Wiley & Sons, Ltd.
(1986) in which we sought to establish (1) that the
direct pathway from BPD symptoms to interper-
sonal dysfunction was significant; (2) that the
pathway from BPD symptoms to emotion regula-
tion problems was significant; (3) that the pathway
from emotion regulation problems to interpersonal
dysfunction was significant after controlling for
BPD symptoms; and (4) that the direct effect of
BPD symptoms predicting interpersonal dysfunc-
tion is reduced, accounting for emotion regulation
problems. In addition, the indirect pathway
from BPD symptoms to emotion regulation pro-
blems to interpersonal dysfunction was tested for
significance by using the Sobel test (Preacher &
Hayes, 2004). These mediation procedures can
establish whether or not the DERS is measuring a
critical component of BPD that fully accounts
for the interpersonal problems associated with
BPD symptoms.
Results
Zero-order correlations between the number of BPD
symptoms endorsed, the IIP total score and the IIP
subscales are presented in Table 1. As shown, there
was a significant direct relationship between BPD
symptoms and IIP total score (p < 0.001), as well
as with each IIP subscale (all p’s < 0.05). The rela-
tion between several non-BPD psychopathology
variables and DERS total score was examined using
univariate ANOVA in which the presence or
absence of each diagnostic category was the pre-
dictor variable and DERS total score was the
outcome variable. DERS total score was found to
be significantly related to lifetime history of
depressive disorder (F(1, 118) = 43.18, p < 0.001),
anxiety disorder (F(1, 118) = 51.15, p < 0.001), and
non-BPD personality disorder (F(1, 119) = 51.22,
p < 0.001). All analyses, therefore, statistically
controlled for the effect of these psychopathology
variables. Gender, ethnicity and marital status
were also examined using univariate ANOVA
and were found to be unrelated to DERS or IIP total
scores. Zero-order correlations also showed that
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 Emotion REG and interpersonal functioning in BPD

15.8 (9.3)
neither DERS nor IIP total score was related to
8 participant’s income or age; thus, no demographic
variables were controlled for in the analyses. Alpha
was set at 0.05 for all analyses.
First, a direct path between the number of

15.6 (10.7)
0.80***
endorsed SCID-II BPD symptoms and the IIP total
7

score was established using hierarchical regression

(b = 0.42, t(118) = 4.5, p < 0.001). To examine
whether or not this path was mediated by DERS
17.7 (10.5)

total score, first, the path from BPD symptoms to

0.82***
0.87***
DERS total score was examined and found to be
6

significant (b = 0.57, t(117) = 7.14, p < 0.001).

SD, standard deviation; DERS, Difficulties with Emotion Regulation Scale; IIP, Inventory of Interpersonal Problems.

Next, BPD symptoms and DERS total score were

entered simultaneously with IIP total score as the
7.5 (6.6)
0.76***
0.62***
0.61***

criterion variable. Results show that the path from

5

DERS total score to IIP total score was significant

(b = 0.73, t(117) = 8.52, p < 0.001), whereas the
path from BPD symptoms to IIP total score was
13.3 (9.0)
0.62***
0.63***
0.70***
0.54***

no longer significant (b = 0.00, t(117) = 0.006,

4

p = 0.99). Thus, the requirements of Baron and

Kenny (1986) for full mediation were met. The
Table 1: Correlations between study variables; means (SD) presented on the diagonal

Sobel test (Preacher & Hayes, 2004) also confirmed

that the indirect path was significant (Sobel = 5.47,
70.0 (40.5)
0.80***
0.80***
0.94***
0.92***
0.89***

p < 0.001). This model accounted for 68% of

3

the variance in IIP score (R2 = 0.68, F = 47.15,

p < 0.001).
To further examine which specific IIP subscales
86.4 (31.5)

the DERS may be accounting for, each IIP subscale

0.81***
0.57***
0.66***
0.80***
0.72***
0.75***

was entered separately into the first model described

2

previously. After the control variables were entered,

a significant direct path from BPD to each subscale
was established for all subscales: interpersonal
2.6 (3.1)

ambivalence (b = 0.29, t(118) = 2.63, p < 0.01);

0.64***
0.75***
0.62***
0.37***
0.53***
0.67***
0.50***
1

interpersonal aggression (b = 0.32, t(118) = 3.27,

p < 0.001); interpersonal sensitivity (b = 0.46,
t(118) = 5.01, p < 0.001); lack of sociability
IIP—need for social approval

(b = 0.26, t(118) = 2.53, p < 0.05); and

need for social approval (b = 0.49, t(118) = 5.16,
IIP—lack of sociability

p < 0.001). The DERS total score mediator was

IIP—ambivalence

then entered simultaneously with BPD symptoms

IIP—aggression
IIP—sensitivity
BPD symptoms

IIP total score

predicting each of these significant criterion IIP

***p < 0.001.

subscale variables. Full mediation, as indicated

**p < 0.01.
*p < 0.05.

by a significant path from the DERS score to

DERS

each IIP subscale, a now insignificant path between

BPD symptoms and the IIP subscale, and a
1.
2.
3.
4.
5.
6.
7.
8.

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Herr et al.

Table 2: Indirect path analyses for BPD symptoms predicting interpersonal problems, mediated by emotion regulation

Dependent Independent(s) b t Sobel R2 (full model) F (full model)

Emotion regulation (DERS)† BPD symptoms (SCID-II) 0.57 7.14***

IIP—interpersonal ambivalence BPD symptoms 0.14 1.15

Emotion regulation 0.68 5.55*** 4.23*** 0.35 12.31***

IIP—interpersonal aggression BPD symptoms 0.00 0.04

Emotion regulation 0.52 4.87*** 3.87*** 0.51 23.32***

IIP—interpersonal sensitivity BPD symptoms 0.07 0.80

Emotion regulation 0.67 7.80*** 5.22*** 0.68 46.93***

IIP—lack of sociability BPD symptoms 0.20 1.97

Emotion regulation 0.76 7.58*** 5.11*** 0.56 28.57***

IIP—need for social approval BPD symptoms 0.12 1.22

Emotion regulation 0.63 6.60*** 4.76*** 0.60 33.74***

DERS, Difficulties with Emotion Regulation Scale; IIP, Inventory of Interpersonal Problems; SCID-II, Structured Clinical
Interview for DSM-IV Personality Disorders, Axis II.
†
Note that this analysis was used to determine the Sobel statistic in all subsequent analyses.
Models include lifetime history of depressive or anxiety disorder and lifetime history of a non-BPD personality disorder as
control variables.
*p < 0.05.
**p < 0.01.
***p < 0.001.

significant Sobel test, was found for all subscales Discussion

(Table 2).
To examine a competing hypothesis, an alter-
native mediational model was tested in which
IIP total score was the mediator between BPD
symptoms and DERS total score. The paths from
BPD symptoms to DERS total score (criterion
variable) and to IIP total score (mediator) were
significant, as reported in the analyses given
previously. When BPD symptoms and IIP total
score were entered simultaneously predicting
DERS total score, IIP was a significant predictor
(b = 0.54, t(117) = 8.52, p < 0.001), but the
path from BPD symptoms remained significant
(b = 0.35, t(117) = 5.10, p < 0.001). The Sobel
test of the indirect path was significant, however,
indicating partial mediation (Sobel = 3.98, p < 0.001).
This model accounted for 77% of the
variance in DERS score (R2 = 0.77, F = 75.42,
p < 0.001).
Difficulties with emotion regulation and interper-
sonal dysfunction are core problems in BPD. How-
ever, research has yet to clearly elucidate how
these constructs relate to one another in the
manifestation of BPD symptoms. Accordingly,
the present study sought to examine the relation-
ships among difficulties with emotion regulation,
interpersonal problems and symptoms of BPD in
a community sample of ethnically diverse adults.
On the basis of Linehan’s biosocial model of
BPD (Linehan, 1993), we hypothesized that
problems with emotion regulation would have a
central role underlying the expression of interper-
sonal problems in BPD. As such, a model in which
difficulties with emotion regulation (measured by
the DERS) mediated the relationship between
BPD symptoms and interpersonal functioning
(measured by the IIP) was tested. We also tested

Copyright © 2012 John Wiley & Sons, Ltd. (2012)

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variations of this model with specific interpersonal
functioning subtypes as the outcome variables. In
addition, we examined an atheoretical model in
which interpersonal functioning mediated the rela-
tionship between BPD symptoms and difficulties
with emotion regulation.
The primary finding of this study supported our
hypothesis that difficulties with emotion regulation
would fully mediate the relationship between BPD
symptoms and interpersonal functioning. In other
words, although BPD symptoms were found to be
directly associated with interpersonal problems, dif-
ficulties with emotion regulation fully accounted for
this relationship. Furthermore, this was true for all
subtypes of interpersonal functioning measured by
the IIP. These findings lend empirical support to
the notion that emotion regulation difficulties are
a key mechanism through which individuals with
BPD may experience more interpersonal problems.
Our findings are supported by previous studies that
found interpersonal problems to be highly related
to emotion regulation or affective instability. For
instance, Bagge and colleagues (2004) showed that
the BPD feature of affective instability, one aspect
of emotion regulation, was related to social malad-
justment even after controlling for other Axis I
and Axis II disorders, which led the authors to
suggest that affective instability may be one cause
of social problems for individuals with many BPD
characteristics. Our findings also support theoretical
models of emotion regulation broadly (e.g. Keltner
& Kring, 1998) and in BPD specifically (e.g.
Putnam & Silk, 2005), which suggest that difficulty
regulating intense emotional experiences account
for problems with interpersonal functioning. Fur-
thermore, our subsequent analyses with specific
subtypes of interpersonal problems showed that
difficulties with emotion regulation could fully
account for the relationship between BPD symp-
toms and each IIP subscale, lending further
support to the notion that difficulties with emotion
regulation underlie a broad range of interpersonal
problems that are associated with BPD.
Our test of the atheoretical alternative model
showed that interpersonal functioning was a partial
Copyright © 2012 John Wiley & Sons, Ltd.
Emotion REG and interpersonal functioning in BPD
mediator of the relationship between BPD symp-
toms and difficulties with emotion regulation. This
finding suggests that some of the difficulties with
emotion regulation that are found among indivi-
duals with many BPD symptoms may be accounted
for by interpersonal functioning problems these
individuals also experience. To fully interpret this
finding, however, we must take into account the test
of the first model and the limitations inherent in
using cross-sectional data for these analyses. When
one uses cross-sectional data to examine mediation,
the predictor, mediator and outcome variables are
determined by a theoretical model rather than
temporal sequencing. Because we compared cross-
sectional models, which differ only by exchanging
the mediator and outcome variables, the direction
of effect between difficulties with emotion regula-
tion and interpersonal functioning could not be
established; thus, some of the observed strength
of the indirect pathway in each model may be
inflated by any portion of the association between
these variables that is due to the outcome causing
the mediator (i.e. the reverse of what a mediation
model specifies). The data show that BPD symp-
toms were directly related to difficulties with
emotion regulation, which, in turn, fully accounted
for the poorer interpersonal functioning associated
with more BPD symptoms. On the other hand,
BPD symptoms were also directly related to pro-
blems in interpersonal functioning, but these
problems only accounted for a portion of the
greater difficulties in emotion regulation among
these individuals. As such, the test of the first
model yields both a stronger result and supports
existing theoretical and empirical research (Bagge
et al., 2004; Linehan, 1993; Stepp et al., 2009).
The results of the second model, however, suggest
the need for further study to determine whether
the indirect effect of interpersonal functioning was
the result of statistical inflation or if there is, in fact,
a bidirectional causal relationship between inter-
personal functioning and difficulties with emotion
regulation that leads to high levels of these con-
structs among individuals with many symptoms
of BPD.
(2012)
DOI: 10.1002/pmh
Herr et al.
There are several additional limitations that must
be considered in the present study. First, self-report
measures of problems with emotion regulation and
interpersonal functioning were used. It is possible
that this resulted in statistical relationships between
measures due to method overlap and raises the ques-
tion of whether or not individuals can accurately
rate their own problems with emotion regulation
and interpersonal functioning. However, this con-
cern is somewhat mitigated by the fact that the mea-
sures chosen for the present study are well validated
and commonly used to study these constructs as they
relate to BPD symptoms in community samples
similar to the present study. A related limitation
is that the questionnaires chosen may not compre-
hensively measure difficulties with emotion regula-
tion or interpersonal functioning and instead only
assess some aspects of these complex and multi-
dimensional constructs. Future studies designed to
replicate and extend the present findings should
include more objective behavioural and biological
measures of emotion regulation (e.g. Herpertz,
Kunert, Schwenger, & Sass, 1999; Herpertz et al.,
2000) and interpersonal functioning to better
understand the relationship between these two core
areas of impairment in BPD.
As noted previously, the study was also limited
by its cross-sectional design, precluding causal infer-
ences about the temporal nature of the relationship
between difficulties with emotion regulation, inter-
personal problems and BPD symptoms. Despite
our results showing that difficulties with emotion
regulation completely accounted for the relationship
between interpersonal problems and BPD symptoms,
it is possible that emotion regulation difficulties
developed, at least in part, from attachment-based
or other relationship problems that occurred earlier
in life. Alternatively, Linehan’s (1993) biosocial
model of BPD posits that the disorder stems from
the interaction between a biologically mediated
predisposition to emotion regulation problems and
invalidation from interpersonal (mostly familial)
relationships. The present data cannot be used
to comprehensively evaluate the developmental,
interactive or transactional relationship between
Copyright © 2012 John Wiley & Sons, Ltd.
interpersonal functioning and emotion regulation
difficulties in BPD individuals; thus, further studies
using longitudinal designs are warranted.
Clinically, the findings of the present study
suggest that the interpersonal problems found in
individuals with a high number of BPD symptoms
may be a function of the emotion regulation pro-
blems that these individuals experience. Addressing
these emotion regulation problems in behavioural
treatments may, therefore, lead to improvement in
the interpersonal functioning of individuals with
BPD symptoms. For instance, there are a range of
emotion regulation skills in dialectical behaviour
therapy (Linehan, 1993) that could be provided to
patients with many dialectical behaviour therapy
symptoms. Although results from the present study
should not be interpreted definitively, the findings
point to the possibility of exploring the sequencing
of emotion regulation skill training before interper-
sonal skill training to reduce BPD symptoms. Before
clinical interventions are tested in this manner,
however, future research must be performed to
better understand the temporal or causal relation-
ship between difficulties with emotion regulation
and interpersonal functioning in BPD.
Acknowledgements
The work was supported by funding from the Brout
Family Foundation, SENetwork and departmental
funds that accrued from clinical revenue. We thank
Dr Jennifer Brout for her support of this research.
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Address correspondence to: Nathaniel R. Herr,
Department of Psychology, American University,
Asbury 321A, 4400 Massachusetts Ave NW,
Washington, D.C. 20016. E-mail: nherr@american.
edu.
(2012)
DOI: 10.1002/pmh