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Comprehensive Psychiatry 51 (2010) 275 – 285

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An experimental investigation of emotional reactivity and delayed

emotional recovery in borderline personality disorder: the role of shame
Kim L. Gratza,⁎, M. Zachary Rosenthalb , Matthew T. Tulla , C.W. Lejuezc , John G. Gundersond
a
Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS 39216, USA
b
Duke University Medical Center, Durham, NC 27710, USA
c
Center for Addictions, Personality, and Emotion Research and the Department of Psychology, University of Maryland, College Park, MD 20742, USA
d
Department of Psychiatry, McLean Hospital and Harvard Medical School, Belmont, MA 02478, USA

Abstract

Despite the emphasis on emotional reactivity and delayed emotional recovery in prominent theoretical accounts of borderline personality
disorder (BPD), research in this area remains limited. This study sought to extend extant research by examining emotional reactivity (and
recovery following emotional arousal) to 2 laboratory stressors (one general, and the other involving negative evaluation) and exploring the
impact of these stressors on subjective responding across the specific emotions of anxiety, irritability, hostility, and shame. We hypothesized
that outpatients with BPD (compared to outpatients without a personality disorder; non-PD) would demonstrate heightened subjective
emotional reactivity to both stressors, as well as a delayed return to baseline levels of emotional arousal. Results provide evidence for
context- and emotion-specific reactivity in BPD. Specifically, BPD participants (compared to non-PD participants) evidenced heightened
reactivity to the negative evaluation but not the general stressor. Furthermore, results provide support for shame-specific reactivity in BPD,
with BPD participants (vs non-PD participants) evidencing a significantly different pattern of change in shame (but not in reported anxiety,
irritability, or hostility) across the course of the study. Specifically, not only did BPD participants report higher levels of shame in response to
the negative evaluation, their levels of shame remained elevated following this stressor (through the post-recovery period at the end of the
study). Findings suggest the importance of continuing to examine emotional reactivity in BPD within specific contexts and across distinct
emotions, rather than at the general trait level.
© 2010 Elsevier Inc. All rights reserved.

1. Introduction reactions to stimuli) and delayed recovery (ie, slow return

Problems with the experience and expression of emotions
are considered to be central to borderline personality disorder
(BPD) [1,2], with the higher-order trait of emotional
dysfunction identified by many BPD researchers as a
“core” personality trait underlying the disorder. Although
several different lower-order emotion-related traits have
been linked at a theoretical and empirical level to BPD,
including affective instability [2], anxiousness [3], affect
intensity [1], and anxiety sensitivity [4], 2 lower-order traits
considered to be particularly relevant to BPD are emotional
reactivity (ie, the tendency to have strong emotional
⁎ Corresponding author. Tel.: +1 601 815 6450.
E-mail address: klgratz@aol.com (K.L. Gratz).
0010-440X/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.comppsych.2009.08.005
to baseline levels of emotional arousal following the
activation of an emotion) [1]. In fact, even the characteristic
of affective instability (see references [2,5,6]) was defined in
the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) to emphasize emotional reactivity
(see reference [7]).
Yet, despite the emphasis on emotional reactivity and
delayed recovery in prominent theoretical accounts of BPD
[1], research in this area remains relatively limited and no
studies have examined emotional reactivity and delayed
recovery in regard to specific emotional states and contexts.
Thus, the goal of the current study was to extend extant
research by examining emotional reactivity (and recovery
following emotional arousal) to 2 laboratory stressors and
exploring the impact of different stressors on specific
subjective emotional states.
276 K.L. Gratz et al. / Comprehensive Psychiatry 51 (2010) 275–285
1.1. Emotional reactivity and delayed recovery in BPD
Emotional reactivity broadly refers to responses that
occur within 1 or more systems of emotional responding
(ie, subjective, physiological, motoric/expressive) following
changes in the external or internal environment [8].
Furthermore, emotional reactivity can be differentiated
from the related construct of affect intensity, with the latter
denoting the general tendency to experience intense
emotions across environmental contexts and the former
referring to more discrete and proximal responses to
specific environmental events.
Despite the theorized importance of emotional reactivity
per se to BPD, however, very few studies have examined this
trait in particular, with most studies of self-reported
emotional dysfunction in BPD collapsing across multiple
lower-order traits. For example, although studies using the
Affect Intensity Measure (AIM) [9] provide evidence for
heightened levels of a generalized affect intensity/reactivity
among individuals with BPD (compared to individuals with
other personality disorders or bipolar II disorder) [10,11],
none of these studies has examined the extent to which
emotional reactivity per se is heightened among individuals
with BPD; thus, it is possible that the observed between-
group differences on the AIM are solely the result of
heightened levels of self-reported affect intensity among
individuals with BPD.
Nonetheless, providing preliminary support for a rela-
tionship between emotional reactivity per se and BPD, a
recent study found that BPD features among college students
are positively associated with self-reported negative emo-
tional reactivity [12]. Moreover, despite failing to provide
consistent evidence for heightened psychophysiological
reactivity in BPD [13-18], results of laboratory-based studies
investigating emotional reactivity in BPD provide further
support for heightened subjective emotional reactivity in
BPD. Specifically, 2 studies examining emotional reactivity
to emotionally evocative and neutral images found that
individuals with BPD (compared to healthy controls)
reported greater subjective reactivity to neutral images,
despite demonstrating lower psychophysiological reactivity
to all images [14,15].
Even less research has examined the relationship between
delayed emotional recovery and BPD, with most literature in
this area being theoretical in nature [1]. However, results of a
recent study using an ecological momentary assessment
approach provide suggestive evidence for delayed recovery
following emotional arousal among individuals with BPD,
finding that individuals with BPD reported a longer duration
of emotional distress than healthy controls [19].
The preliminary evidence for heightened subjective
emotional reactivity and delayed emotional recovery in
BPD notwithstanding, further research is needed to examine
the nature and extent of emotional reactivity and delayed
recovery among individuals with BPD across specific
emotional states. In particular, although evidence suggests
that the emotional reactivity and delayed recovery in BPD
may be specific to negative emotions [19,20] (with studies
demonstrating a general underresponsiveness and hypor-
eactivity for positive emotions in BPD; see references
[21,22]), additional research is needed to examine these traits
across distinct negative emotions. Indeed, research on the
related trait of affective instability has found that the
affective instability characteristic of BPD does not involve
all emotions but is emotion-specific [11]. Specifically,
research is needed to examine the particular emotions of
anger, anxiety, and shame, all of which have been
emphasized in the literature on BPD [3,11,23-28].
1.2. Anger and anxiety in BPD
Historically, theoretical and clinical literature on BPD
emphasized the relevance of anger and anxiety to this
disorder [23-25], noting the prominence of these emotions
among individuals with BPD [24-26,29,30]. This literature is
supported by empirical research suggesting the relevance of
these emotions to BPD. For example, in the aforementioned
study of affective instability in BPD, Koenigsberg and
colleagues [11] found that the affective instability charac-
teristic of patients with BPD is specific to anger and anxiety,
with results indicating greater lability of anger and anxiety
(but not depression and elation) among patients with BPD
(vs those with other personality disorders), even when
controlling for mood disorders, gender, and age.
With regard to research on the relevance of anger in
particular to BPD, studies have found heightened levels of
anger, hostility, and irritability among individuals with BPD
(compared to both healthy controls [31] and patients with a
mood disorder [32]), consistent with the theorized centrality
of anger in general [25,29,30], and hostility and irritability in
particular [23,24,33], in BPD. As for research on the
relevance of anxiety to BPD, in addition to evidence that
patients with BPD exhibit elevated symptoms of anxiety (eg,
see references [26,34]) and have high rates of co-occurring
anxiety disorders [35-37], the trait of anxiousness has the
highest loading on the emotion dysregulation factor of the
Dimensional Assessment of Personality Pathology [38],
proposed by Livesley and colleagues [3] to be the core
feature of BPD.
1.3. Shame and BPD
More recently, literature has begun to emphasize the
central role of shame in BPD, with this emotion in particular
thought to underlie some of the most troubling symptoms
associated with this disorder (eg, suicidal behaviors,
deliberate self-harm, and aggressive behaviors) [1,27,28].
Indeed, it has even been suggested that BPD may best be
conceptualized as a chronic shame response [39].
The development of an overwhelming shame response
(or shame-proneness) among individuals with BPD is
thought to begin at an early age in response to chronic
experiences of abuse, neglect, and/or invalidation [27,39].
 K.L. Gratz et al. / Comprehensive Psychiatry 51 (2010) 275–285
Unlike guilt, which is associated with the belief “I have
done something bad,” shame is associated with the belief “I
am bad” [40]. Not surprisingly, guilt and shame have been
found to be differentially related to psychopathology, with
guilt being negatively associated with or unrelated to
psychopathology and shame being positively associated
with psychopathology [40]. Indeed, many of the behaviors
found to be positively associated with shame are common
among individuals with BPD, including interpersonal
hostility [40] and suicidality [41,42].
Although limited, recent empirical research provides
support for the theorized centrality of shame to BPD. For
example, Rüsch et al [27] found that women with BPD
reported higher levels of shame-proneness and state shame
than women with social phobia and healthy controls, in
addition to evidencing a more shame-prone self-concept on
an implicit association test. Yet, although both theoretical
and empirical literature alike suggest the relevance of shame
to the emotional dysfunction of BPD, further research is
needed to examine whether emotional reactivity and delayed
recovery in BPD are differentially related to shame versus
other emotional states.
1.4. The current study
The overall goal of the current study was to extend past
research on emotional reactivity and delayed recovery in
BPD by examining the role of several discrete BPD-
relevant negative emotions (specifically, shame, anxiety,
irritability, and hostility), rather than just negative emotions
in general. Further, this study explored the relevance of 2
different types of laboratory stressors to emotional dys-
function in BPD (one of which was general and the other
which involved negative evaluation). Specifically, we
examined reactivity to a computerized stressor shown to
induce anxiety, irritability, and frustration (the Paced
Auditory Serial Addition Task—Computerized Version
[PASAT-C]; see references [43-45]),and then provided
participants with negative feedback about their performance
during this stressor (thus providing a negatively evaluative
stressor). Self-reported emotional states (ie, anxiety,
irritability, hostility, and shame) were assessed at several
different times throughout the study. It was hypothesized
that, compared to a clinical comparison group of out-
patients without a personality disorder (non-PD), out-
patients with BPD would demonstrate heightened
subjective emotional reactivity to the laboratory stressors,
reporting higher levels of emotions in response to both the
general and negatively evaluative stressors. Furthermore,
we hypothesized that outpatients with BPD (vs non-PD
outpatients) would demonstrate a delayed return to baseline
arousal, as evidenced by a failure to return to baseline
levels of emotional arousal by the end of the final recovery
period. Given that all of the emotions examined in this
study are considered to be BPD-relevant, no specific
hypotheses were made regarding emotion-specific reactiv-
ity or delayed recovery.
277
2. Method
2.1. Participants
Two groups of outpatients (BPD and non-PD) were
recruited through advertisements posted at a psychiatric
hospital and on 2 websites. Participants were required to be
between 18 and 60 years of age and currently receiving
outpatient psychiatric treatment. After providing written
informed consent, potential participants were interviewed
using the Diagnostic Interview for DSM-IV Personality
Disorders [46] and the Current Mood Episodes, Psychotic
Symptoms, and Alcohol and Non-Alcohol Dependence
sections of the Structured Clinical Interview for DSM-IV
Axis I Disorders [47]. Inclusion criteria included either
meeting 5 or more criteria for BPD (BPD group), or not
meeting full criteria for any PD and not meeting more than 3
criteria for BPD (non-PD group). Exclusion criteria for both
groups focused on the presence of Axis I psychopathology
that could influence emotional responding to the stressors,
including current manic, hypomanic, or depressive mood
episodes (but not lifetime history of mood disorders),
current substance dependence, and/or current diagnosis of a
psychotic disorder. Thirty-six participants (18 per group)
completed the experimental portion of the study. However,
after completing the experiment, 1 participant in the BPD
group revealed to the experimenter that he had been
informed about the purpose of the study and use of
deception before participation and had altered his responses
accordingly; thus, this participant was excluded, resulting in
a final sample size of 35.
2.1.1. Borderline personality disorder group
Participants with BPD were predominantly female (88%),
White (77%), single (77%), and highly educated (some
college = 24%; college graduate = 35%; graduate school =
35%), and ranged in age from 18 to 52, with a mean age of
34.06 (SD = 11.15). In regard to their clinical characteristics,
35% of the participants reported at least one inpatient
psychiatric hospitalization in the past year, and 35% reported
past-year treatment in a partial hospitalization program.
Participants received an average of 3.30 (SD = 3.23) hours of
outpatient psychiatric treatment per week and were taking an
average of 3.18 (SD = 1.74) psychiatric medications. With
regard to the particular classes of psychiatric mediations
being taken by participants, 65% reported taking antide-
pressant medications, 53% reported taking anxiolytics, 18%
reported taking antipsychotic medications, 29% reported
taking mood stabilizers, 47% reported taking sleep medica-
tions, and 12% reported taking stimulants. As with most
BPD samples, participants had high rates of Axis II
comorbidity (65%; specifically, avoidant, dependent, and
obsessive-compulsive personality disorders), with 47%
meeting criteria for 1 other personality disorder, 12%
meeting criteria for 2 other personality disorders, and 6%
meeting criteria for 3 additional personality disorders.
278 K.L. Gratz et al. / Comprehensive Psychiatry 51 (2010) 275–285
2.1.2. Clinical comparison group
Non-PD participants were predominantly female (78%),
White (100%), single (61%), and highly educated (some
college = 33%; college graduate = 39%; graduate school =
28%), and ranged in age from 18 to 57, with a mean age of
37.33 (SD = 12.08). In regard to the clinical characteristics of
this group, 17% of the participants reported at least 1 inpatient
psychiatric hospitalization in the past year, and 22% reported
past-year treatment in a partial hospitalization program.
Participants received an average of 2.57 (SD = 3.18) hours of
outpatient psychiatric treatment per week and were taking an
average of 2.56 (SD = 2.62) psychiatric medications. With
regard to the particular classes of psychiatric medications
being taken by participants, 61% reported taking antidepres-
sant medications, 33% reported taking anxiolytics, 11%
reported taking antipsychotic medications, 22% reported
taking mood stabilizers, 39% reported taking sleep medica-
tions, and 6% reported taking stimulants. Finally, it warrants
mention that although participants in the clinical comparison
group were required to not meet full criteria for a personality
disorder, 44% of these participants qualified for a subthresh-
old personality disorder (ie, meeting all but 1 criteria for [at
least] 1 of the personality disorders), indicative of at least
some chronic difficulties.
2.2. Materials
2.2.1. Clinical Interviews
The Current Mood Episodes, Psychotic Symptoms, and
Alcohol and Non-Alcohol Dependence sections of the
Structured Clinical Interview for DSM-IV Axis I Disorders
(SCID-I/P) [47] were used to assess for the exclusion criteria
(including current mood episodes, current substance depen-
dence, and current psychotic disorders). Interviews were
conducted by masters-level clinicians, trained in the
administration of the SCID-I/P. All interviews were
reviewed by a PhD-level clinician (KLG); diagnostic
agreement was 100%.
The Diagnostic Interview for DSM-IV Personality
Disorders (DIPD-IV) [46] was used to assess for the
presence of Axis II personality disorders. The DIPD-IV
has demonstrated good interrater and test-retest reliability
[48], with interrater κ coefficients ranging from 0.68 to 0.73
(based on 84 pairs of raters independently rating 27
videotaped assessments) and a test-retest κ coefficient of
0.69 to 0.74. The DIPD-IV was administered by masters-
level clinicians trained in the administration of this interview.
All interviews were reviewed by a PhD-level clinician
(KLG). In the 3 cases for which a discrepancy in diagnosis
was evident, areas of disagreement were discussed as a group
and a consensus was reached. As a result of the collaborative,
iterative process we used to diagnose PDs, no specific data
on the reliability of the diagnostic assessments are available.
2.2.2. Affect Intensity Measure
The Affect Intensity Measure (AIM) [9] is a 40-item
measure of the characteristic (ie, trait) intensity and reactivity
of emotional responses, independent from the frequency and
hedonic level of emotional responses. Research suggests that
the AIM has high internal consistency and good test-retest
reliability over a period of 2 years [9,49], as well as good
construct validity [9,50-52]. Moreover, evidence for the
convergent validity of the AIM is provided by findings of a
significant association with borderline pathology among a
sample of psychiatric patients [53].
Although Larsen and Diener [9] developed the AIM as
a unidimensional measure of affect intensity, research
suggests that the AIM is multidimensional, measuring
both positive and negative affect intensity and emotional
reactivity [54-57]. Given recent findings that the relation-
ship between affect intensity/reactivity and BPD may be
specific to negative emotions [20], as well as the focus of
the current study on negative emotional reactivity, scores
were computed for both the negative affect intensity and
negative emotional reactivity variables (based on the
criteria of Weinfurt et al [56]). Items were recoded so that
higher scores in every case indicated greater negative
affect intensity or reactivity. The AIM was included in the
present study to provide an assessment of trait negative
affect intensity and emotional reactivity, allowing us to
examine the extent to which trait-based measures of
emotional responding correspond to and/or differ from
real-time assessments of emotional intensity and reactivity
to specific laboratory stressors. Internal consistency in the
current sample was α = .82 for the negative affect
intensity subscale and α = .63 for the negative emotional
reactivity subscale.
2.2.3. Subjective emotional response assessments
Subjective emotional responses were assessed at 5
different time points throughout the experiment. In line
with the methods used in previous studies assessing
reactivity to the laboratory stressor used here (ie, the
PASAT-C; see references [43,45]), participants were asked
to report on their levels of anxiety, irritability, and hostility
throughout the study. In addition, given its suggested
centrality to BPD [28,39], participants also were asked to
rate their levels of shame. Specifically, at baseline and
again at 4 different points throughout the study (see
Procedure), participants were asked to rate the extent to
which they were currently (“right now”) experiencing
anxiety, irritability, hostility, and shame on a scale from 1
(not at all) to 5 (extremely).
2.2.4. Laboratory stressors
This study used a modified version of the PASAT-C,
an empirically-supported laboratory stressor shown to
induce emotional distress in the form of anxiety,
frustration, and irritability [43-45]. During this task,
numbers are sequentially flashed on a computer screen,
and participants are instructed to sum the most recent
number with the previous number (using the computer
mouse to click on the correct answer). After providing
 K.L. Gratz et al. / Comprehensive Psychiatry 51 (2010) 275–285
each sum, the participant must ignore the sum and add
the following number to the most recently presented
number. When a correct answer is provided, a point is
obtained. If an incorrect answer is provided, or if the
participant fails to provide an answer before the next
number is presented, an “explosion” sound is played and
the score does not change.
The version of the PASAT-C used in this study
consisted of 4 levels, the first 3 of which had increasingly
shorter latencies between number presentations. Because
the correct answer must be provided before the presen-
tation of the next number to obtain a point, difficulty
increases as latencies decrease. Level 1 (low difficulty)
had a 3-second latency between number presentations,
Level 2 (medium difficulty) had a 2-second latency, and
Levels 3 and 4 (high difficulty) had a 1-second latency.
The first level lasted 1 minute, the second level lasted 2
minutes, and the third level (which served as a prime for
the final level) lasted 1 minute. Following a brief 60-
second resting period at the end of level 3 to complete the
emotion ratings (to assess reactivity to the PASAT-C and
prevent differing durations in the final level from
influencing the emotion ratings; see references [43,44]),
the final level began. The final level had the same latency
between number presentations as level 3 (ie, 1 second)
but lasted 7 minutes and included an option to terminate
the task at any time.
Immediately following completion of the PASAT-C,
standardized negative feedback appeared on the participants'
computer monitor. Specifically, participants were presented
with the following message: “Your task performance was
[below average]. Compared to others who have completed
the task, your performance was in the [bottom 10%]. Based
on your performance, you will receive [8 minutes], out of a
possible 20 minutes, to solve the anagrams.” (For informa-
tion on the anagrams task, see below.)
2.3. Procedure
All methods used in this study received prior approval by
the institution's institutional review board. After providing
written informed consent, participants completed the screen-
ing interview and self-report questionnaire, for which they
were reimbursed $25. Eligible participants were then
scheduled for the experimental portion of the study. Upon
arrival to the laboratory, participants were informed that the
purpose of the study was to examine performance on 2
problem-solving tasks, 1 of which involved working memory
(PASAT-C) and the other which assessed verbal problem-
solving abilities (anagrams). Participants were provided with
instructions for each of these tasks, and informed that their
performance on the tasks would determine the amount of
money they would receive as reimbursement for their
participation, ranging from $15 to $25 (providing an
incentive to perform well on the tasks). Following provision
of the study instructions, participants were escorted to a study
cubicle, separate from the experimenter. The experimenter
279
turned on the participants' computer monitor, left the cubicle,
and instructed the participant to await further instructions. All
study procedures were computerized, requiring limited
interaction between the participants and experimenter; the
only contact after the start of the experimental procedure
occurred when the experimenter entered the cubicle to read
aloud the experimental instructions that appeared on the
participants' computer screen.
Participants were first asked to rate their levels of
anxiety, irritability, hostility, and shame, providing a
baseline assessment of subjective emotional responses
(Baseline). After a 5-minute resting period, participants
completed the PASAT-C. As described above (see
Laboratory stressors), participants were asked to rate their
current emotional state between Levels 3 and 4 of the
PASAT-C (PASAT-C Reactivity).
Following completion of the PASAT-C and receipt of the
negative feedback (which appeared on their computer screen
immediately after completion of the PASAT-C), participants
were once again instructed to rate their current emotional
state across the 4 emotions of interest (Feedback Reactivity).
Next, participants were provided with a list of 48 solvable
anagrams, each of which contained 6 to 7 letters [58].
Examples include EMKONY (ie, monkey) and NORGEA
(ie, orange). Participants were instructed to solve as many
anagrams as they could in the time provided. All participants
received 8 minutes to work on the anagrams. At the end of
the 8 minutes, participants were instructed to stop working
on the anagrams and were once again asked to report on their
subjective emotional responses (Post-Anagrams). Next,
participants were instructed to sit quietly for 5 minutes,
after which they completed the final ratings of their current
emotional state (Post-Recovery).
Once the experimental procedure was completed,
participants were guided through a brief relaxation
exercise (designed to alleviate any lingering distress).
After the relaxation exercise, participants were fully
debriefed about the purpose of the study, the use of
deception, and the rationale for providing the false
feedback. Participants also were provided with a list of
coping strategies for managing distress. All participants
(regardless of their performance) were reimbursed $25 for
participation in this part of the study.
3. Results
3.1. Preliminary analyses
A series of t tests and χ2 analyses were conducted on
relevant demographic (ie, age, gender, and racial/ethnic
background) and clinical (ie, amount of therapy, number
of psychiatric medications, rates of use of the different
classes of psychiatric medications [ie, antidepressants,
anxiolytics, antipsychotics, mood stabilizers, sleep medi-
cations, and stimulants], and past-year hospitalization
rates) characteristics to determine equivalence across
280 K.L. Gratz et al. / Comprehensive Psychiatry 51 (2010) 275–285
1
groups. Results indicate no significant between-group
differences on any of these variables (ts b 1.00, χ2 s b
1.37; η2p s b 0.05, contingency coefficients b 0.19; Ps N
.10), with one exception: significantly more BPD partici-
pants than non-PD participants self-identified as non-
White (χ2 = 4.78, P b .05). Given that none of the
dependent variables was significantly associated with
racial background, however, this variable was not included
as a covariate in later analyses.
Furthermore, preliminary analyses were conducted to
examine between-group differences in performance on the
laboratory tasks (expected to influence participants' emo-
tions in response to and following the tasks). Results
indicate that the groups did not differ significantly in
performance on the PASAT-C (t = 1.06, P N .10) or
anagrams task (t = 0.13, P N .10).
3.2. Analysis plan
To examine between-group differences in trait negative
emotional intensity and reactivity, a 1-way (BPD vs non-PD)
multivariate analysis of variance (MANOVA) was con-
ducted on the negative affect intensity and negative
emotional reactivity variables from the AIM. Likewise, to
examine between-group differences in subjective emotional
responses at the various time points throughout the study, a
1-way (BPD vs non-PD) MANOVA was conducted with
self-reported anxiety, irritability, hostility, and shame across
the 5 assessment points (ie, Baseline, PASAT-C Reactivity,
Feedback Reactivity, Post-Anagrams, and Post-Recovery)
serving as the dependent variables.
To examine between-group differences in the pattern of
change in subjective emotional responses following exposure
to the first laboratory stressor (ie, the PASAT-C) through
postrecovery, a series of 2 (group) × 4 (assessment point)
1
Analyses were also conducted to explore more fully the effect of
psychiatric medication use on the outcomes of interest. To this end, we
conducted a series of exploratory analyses examining the associations
between the use of different classes of medication (ie, antidepressants,
anxiolytics, antipsychotics, mood stabilizers, sleep medication, and
stimulants), as well as the number of medications, and self-reported
emotional responses at each of the assessment points (ie, Baseline,
PASAT-C Reactivity, Feedback Reactivity, Post-Anagrams, and Post-
Recovery). Findings indicated that the use of antidepressant, anxiolytic,
antipsychotic, or sleep medications was not significantly associated with
self-reported emotional responses at any assessment point. However, the
use of stimulant medications was associated with higher levels of anxiety
and shame at several assessment points (Fs N 6.12, Ps b .05); the use of
mood stabilizers was associated with higher levels of hostility following
the anagrams (F1,33 = 4.91, P b .05); and number of medications was
positively associated with levels of shame at Post-Recovery (r = 0.41, P b
.05) and levels of anxiety at baseline, post-recovery, and after the negative
feedback (r's N 0.35, P's b .05). Given these findings, we examined
whether the results of our primary analyses changed when controlling for
the use of different classes of psychiatric medications or the number of
medications used. The results of the repeated measures analyses of
covariance (see Section 3.3.2) did not change when controlling for
medication status across the different classes of medications or number of
different psychiatric medications.
repeated measures analyses of covariance (ANCOVAs;
controlling for baseline levels of that emotional response, as
well as performance on the laboratory tasks) were conducted
on anxiety, irritability, hostility, and shame. In all repeated
measures ANCOVAs, the multivariate test statistic was used.
For those analyses indicating a statistically significant group
by assessment point interaction effect, the following post hoc
analyses were conducted: (a) 1-way (BPD vs non-PD)
ANCOVAs (controlling for baseline levels of the emotional
response and task performance) were used to examine
between-group differences in emotional responses at each
assessment point; (b) 1-way (Baseline vs Post-Recovery)
repeated measures ANCOVAs (controlling for performance
on the laboratory tasks) conducted within each group
separately were used to examine changes in levels of the
emotional response from baseline to post-recovery; (c) 1-way
within-group repeated measures ANCOVAs (controlling for
baseline levels of that emotional response, as well as
performance on the laboratory tasks) were used to examine
changes in levels of the emotional response from its peak level
to postrecovery; and (d) independent-sample t tests were
conducted to examine between-group differences in the slopes
of the lines from the highest point of arousal to both the next
time point (to examine between-group differences in the rate
of emotional recovery immediately following peak arousal)
and post-recovery (to investigate between-group differences
in the rate of recovery from peak arousal to the end of the
study). For all analyses, α was set at .05, using the more
conservative 2-tailed test.
3.3. Primary analyses
3.3.1. Trait negative emotional intensity and reactivity
Results provide evidence for the differential relevance of
trait negative emotional intensity and reactivity to BPD,
suggesting the importance of examining these emotion-
related traits separately. Specifically, although the overall
effect of group on trait negative emotional intensity and
reactivity was significant (Wilks Λ = .52, F2,32 = 14.96, P b
.001, multivariate η2p = 0.48), examination of the univariate
effects revealed significant between-group differences in
only negative emotional intensity, with BPD participants
reporting significantly higher levels of negative emotional
intensity than non-PD participants (BPD = 46.00 ± 4.95;
non-PD = 35.33 ± 6.29; F1,33 = 30.85, η2p = 0.48; P b .01).
The groups did not differ significantly in trait negative
emotional reactivity (BPD = 25.94 ± 4.85; non-PD = 24.06 ±
3.96; F1,33 = 1.59, η2p = 0.05; P N .10).
3.3.2. Emotional reactivity and recovery in response to the
laboratory stressors
Means and standard deviations for self-reported emotional
responses across all assessment points are presented in
Table 1. Results of the MANOVA examining between-
group differences in self-reported emotional responses
revealed a significant overall effect of group (Wilks Λ = .19,
F14,20 = 3.02, P b .05, multivariate η2p = 0.81). Consistent with
 K.L. Gratz et al. / Comprehensive Psychiatry 51 (2010) 275–285 281

Table 1 significant between-group difference in shame in response

Descriptive and inferential statistics for between-group differences in to the PASAT-C (PASAT-C Reactivity; F1,31 = .43, η2p =
emotional responses
0.01, P N .10), BPD participants reported significantly
BPD Non-PD Test statistic higher levels of shame after the negative feedback (F1,31 =
(n = 17) (n = 18)
5.64, η2p = 0.15, P b .05). Furthermore, additional post hoc
Mean SD Mean SD F η2p ANCOVAs (controlling for baseline levels of shame and
Anxiety performance on both the PASAT-C and anagrams task)
Baseline 2.94 0.93 2.08 1.02 6.73⁎ 0.17 revealed that their levels of shame remained significantly
PASAT-C Reactivity 3.09 1.18 2.14 1.12 5.98⁎ 0.15 higher than the non-PD group at all subsequent time points
Feedback Reactivity 2.97 1.39 2.06 1.36 3.89 0.11
Post-Anagrams 2.71 1.06 2.25 1.19 1.42 0.04
(ie, post-anagrams and post-recovery) (F's1,30 N 6.71, η2ps ≥
Post-Recovery 2.41 0.96 1.89 1.08 2.29 0.07 0.18, Ps b .05), and did not decrease significantly over the
Irritability remaining time points (F2,12 = 1.59, η2p = 0.21, P N .10).
Baseline 2.24 1.20 1.33 0.59 8.08⁎⁎ 0.20 Finally, although both groups reported higher levels of
PASAT-C Reactivity 3.00 1.28 2.22 0.88 4.46⁎ 0.12 shame at the end of the recovery period (compared to
Feedback Reactivity 3.29 1.11 2.06 1.35 8.77⁎⁎ 0.21
Post-Anagrams 2.88 1.36 2.28 1.02 2.23 0.06
baseline), this difference was statistically significant only for
Post-Recovery 2.82 1.07 1.94 0.87 7.08⁎ 0.18 the BPD participants (for BPD: F1,14 = 6.02, η2p = 0.30, P b
Hostility .05; for non-PD: F1,15 = 3.50, η2p = .19; P N .08).
Baseline 1.35 0.61 1.00 0.34 4.56⁎ 0.12 Interestingly, however, post hoc analyses examining be-
PASAT-C Reactivity 2.18 1.29 1.44 0.62 4.70⁎ 0.13 tween-group differences in the slopes of the lines from
Feedback Reactivity 2.24 1.20 1.28 0.75 8.10⁎⁎ 0.20
Post-Anagrams 2.06 1.03 1.67 0.91 1.43 0.04
participants' peak levels of shame (ie, PASAT-C Reactivity
Post-Recovery 2.06 1.03 1.22 0.43 10.07⁎⁎ 0.23 for non-PD participants and Feedback Reactivity for BPD
Shame participants; see Fig. 1) to both the following period and
Baseline 2.24 1.20 1.06 0.24 16.73⁎⁎ 0.34 post-recovery revealed no significant differences in the rate
PASAT-C Reactivity 2.94 1.34 1.67 1.19 8.85⁎⁎ 0.21 of emotional recovery across the groups. Specifically,
Feedback Reactivity 3.53 1.55 1.78 1.31 13.14⁎⁎ 0.29
Post-Anagrams 3.41 1.46 1.83 1.10 13.16⁎⁎ 0.29
findings indicated no significant between-group differences
Post-Recovery 3.29 1.45 1.56 1.04 16.78⁎⁎ 0.34 in the slopes of the lines from participants' peak levels of
⁎ P b .05. shame to either the following period (t33 = 1.30, P = .20) or
⁎⁎ P b .01. post-recovery (t33 = 0.38, P = .71).

4. Discussion
findings of higher levels of trait negative affect intensity
among BPD participants, examination of the univariate effects
The purpose of this study was to extend extant research on
revealed that BPD (vs non-PD) participants reported signif-
emotional reactivity and delayed emotional recovery in BPD
icantly higher levels of all emotional responses at baseline.
Thus, all primary repeated measures analyses reported below
will control for baseline levels of the emotional response.
Results indicate no between-group differences in the
pattern of change in anxiety, hostility, or irritability over the
course of the study, as the group × assessment point
interaction was not significant for anxiety (F3,28 = 0.84, η2p =
0.08, P N .10), hostility (F3,28 = 1.95, η2p = 0.17, P N .10), or
irritability (F3,28 = 2.28, η2p = 0.20, P N .10).
Interestingly, however, analyses did provide evidence for
between-group differences in emotional reactivity and
recovery for the emotion of shame, indicating a significant
group × assessment point interaction effect (F3,28 = 3.91,
η2p = 0.30, P b .05) (see Fig. 1).2 Post hoc ANCOVAs
(controlling for baseline levels of shame and performance on
the PASAT-C) revealed that although there was no

2
Given evidence of gender differences in emotional intensity and
reactivity [9,51,52], as well as the fact that most of the sample was female, the
same analysis was conducted among just the female participants (to ensure that
the findings are applicable to women in particular). Findings among the
subsample of female participants (n = 29) were the same as those obtained
among the larger mixed-gender sample, indicating a significant group × Fig. 1. Group by assessment point interaction for shame (controlling for
assessment point interaction effect for shame (F3, 22 = 3.16, η2p = 0.30, P b .05). baseline levels of shame and performance on the laboratory tasks).
282 K.L. Gratz et al. / Comprehensive Psychiatry 51 (2010) 275–285
by examining the precise nature and extent of these traits in
BPD, especially with regard to specific emotional states and
the contexts in which these emotions occur. To this end, this
study examined emotional reactivity (and recovery follow-
ing emotional arousal) to 2 different laboratory stressors,
exploring the impact of these stressors on subjective
responding across the specific emotions of anxiety, irritabil-
ity, hostility, and shame.
Consistent with prominent theoretical accounts of BPD [1],
findings provide some evidence for subjective emotional
reactivity in BPD. However, rather than suggesting the
presence of a generalized emotional reactivity in BPD, results
provide evidence for context-dependent and emotion-specific
reactivity in BPD. Indeed, findings indicated no group
differences in trait negative emotional reactivity. Furthermore,
whereas BPD participants (compared to non-PD participants)
evidenced heightened reactivity in response to the negative
evaluation, BPD and non-PD participants did not differ in
their reactivity to the general laboratory stressor (which has
been found in previous research to induce emotional distress
in the form of anxiety, frustration, and irritability) [43-45]. As
such, results suggest that the heightened emotional reactivity
within BPD may be context-dependent, and more likely to
occur in response to stressors such as negative evaluation than
more general stressors.
Likewise, evidence suggests that the emotional reactivity
and delayed recovery in BPD may be specific to particular
emotional responses. That is, whereas BPD participants did
not evidence a different pattern of change in subjective
anxiety, irritability, or hostility across the course of the study
than non-PD participants, they did evidence a significantly
different pattern of change in shame. Specifically, not only
did BPD participants report higher levels of shame in
response to the negative evaluation, their levels of shame
remained elevated following this stressor (through the post-
recovery period at the end of the study). Furthermore, only
BPD participants reported significantly higher levels of
shame at the end of the study (relative to their baseline
levels). Importantly, however, post hoc analyses indicated no
differences in the rate of emotional recovery across groups,
suggesting that although BPD individuals may demonstrate a
delay in the return to baseline levels of shame (relative to
non-PD individuals), this is likely the result of the magnitude
of their emotional reaction rather than the maintenance of
emotional arousal once activated. Thus, although findings
provided evidence for shame-specific delayed recovery
among participants with BPD, this delayed recovery was
due to the greater intensity of their shame response rather
than a slower rate of emotional recovery. Altogether, these
findings suggest the importance of continuing to examine
emotional reactivity and recovery in BPD across specific
contexts and emotions, rather than at the more general trait
level (which may obscure the complexity and intricacies of
these characteristics in BPD).
Findings also provide evidence for the differential
relations of emotional intensity and emotional reactivity to
BPD, highlighting the importance of investigating these
traits in BPD separately (rather than collapsing across these
traits when examining emotional dysfunction in BPD).
Indeed, in contrast to evidence that the emotional reactivity
in BPD may be emotion- and context-specific (rather than
generalized), result suggests the presence of a generalized
heightened emotional intensity in BPD. Specifically, not
only did BPD participants report significantly higher levels
of trait negative emotional intensity, they reported signifi-
cantly higher levels of all emotional responses at baseline.
These findings are consistent with theories implicating an
underlying emotional intensity in the pathogenesis of BPD
[1] and suggest that there may be important differences in the
nature and extent of emotional intensity (vs emotional
reactivity) in BPD, with intensity being a more generalized
vulnerability than reactivity.
Although promising, the results of the present study are
preliminary and must be evaluated in light of the study's
limitations. First and foremost, this study used a small and
homogenous sample of participants, potentially limiting our
statistical power and ability to detect between-group
differences, as well as the generalizability of the results.
Moreover, the decision to exclude participants with a current
mood episode (due to the fact that the presence of such an
episode could influence task performance) may further limit
the generalizability of the findings, especially with regard to
BPD, as outpatients with BPD commonly present with co-
occurring mood disorders [2]. Thus, replication of these
findings in larger, more diverse, and more representative
samples is needed.
Another sample-related limitation concerns our compar-
ison group. Although the use of a clinical comparison
group is an asset of this study (providing a more stringent
control group than a normal or nonpsychiatric control
group), the specific Axis I conditions present within this
group were not assessed and significant Axis II psychopa-
thology was explicitly excluded. Thus, the specificity of
our findings to BPD (vs PDs in general) is unclear. Future
studies are needed to explore whether the pattern of
context- and emotion-specific reactivity found here is
specific to BPD or associated with PDs more broadly.
Only by controlling for the presence of other PD symptoms
or specifically comparing individuals with BPD to those
with other PDs will future research be able to speak to the
specificity of these findings to BPD in particular. For
example, although clinical and empirical literature empha-
sizing the centrality of shame to BPD [27,28,39] suggests
that our findings may be BPD-specific, it is also possible
that the experience of shame (and heightened shame
reactivity) is associated with the presence of another PD
(in particular, narcissistic personality disorder; see reference
[59]). However, given that none of the BPD participants
met criteria for narcissistic personality disorder, it is
unlikely that findings are solely related to the presence of
co-occurring narcissistic personality pathology among the
BPD participants.
 K.L. Gratz et al. / Comprehensive Psychiatry 51 (2010) 275–285
Data on the specific forms of Axis I psychopathology
present within this sample also would provide valuable
information on the specificity of these findings to BPD, and
the ways in which emotional reactivity in BPD compares to
emotional reactivity within other specific clinical groups. In
particular, the absence of data on the anxiety disorder
diagnoses of participants limits our ability to determine the
extent to which findings of heightened shame reactivity are
related to BPD specifically (rather than co-occurring
anxiety disorders within the BPD group, such as social
anxiety disorder). However, it warrants mention that
comparable rates of participants in both groups were
receiving treatment of anxiety disorder-related difficulties,
and results did not change when anxiety-disorder focused
treatment status was included in the analyses as a
covariate.3 Nonetheless, to further address the specificity
of these findings to BPD, future studies should include a
more thorough assessment of Axis I psychopathology in
general (and anxiety disorders in particular) and control for
the presence of specific anxiety disorders across groups.
Moreover, given that context-specific emotional reactivity
is thought to play a central role in certain anxiety disorders
as well (eg, PTSD and GAD; see references [60,61]), future
research should examine whether the context-specific
emotional reactivity observed here is more pronounced in
BPD than in these other disorders.
Likewise, the absence of data on general psychiatric
symptom severity and/or global impairment limits our ability
to speak to the effects of psychopathology on our findings.
Nonetheless, the comparableness of these groups with
respect to relevant clinical characteristics (including amount
of treatment, number and type of psychiatric medications,
and past year hospitalization rates) suggests that our findings
reflect more than simply severity of psychopathology. To
further clarify this issue, however, future studies should
3 evaluate their emotional experiences.
Although the inclusion of baseline levels of emotional responses as a
covariate in analyses examining the pattern of change in emotional
responses over the course of the study limits concerns regarding the
potential confounding influence of co-occurring anxiety disorders on
baseline emotional responses, exploratory analyses were conducted to
examine the potential influence of anxiety-related difficulties on the results.
First, a χ2 analysis was conducted to examine between-group differences in
the rate of participants currently receiving some form of treatment for
anxiety disorder-related difficulties (including individual psychotherapy,
group therapy, and/or pharmacotherapy). Findings indicate that rates of
anxiety disorder-focused treatment did not differ between groups (with 53%
of the BPD participants and 39% of the non-PD participants receiving some
form of treatment focused on anxiety disorder–related difficulties; χ2 = .70,
P = .40). Next, we conducted a series of analyses examining the
associations between anxiety disorder–focused treatment status (yes vs
no) and self-reported emotional responses at each of the assessment points
and exploring whether the results of our primary analyses changed when
controlling for this variable. Results indicate that anxiety disorder–focused
treatment status was not significantly associated with self-reported
emotional responses at any assessment point (P's N .10). Furthermore,
results did not change when anxiety disorder–focused treatment status was
included as a covariate in the repeated measures ANCOVAs.
283
include a more thorough assessment of general symptom
severity/impairment.
Limitations with regard to the experimental procedures
also warrant mention. For example, the examination of only
4 BPD-relevant emotions may have limited our ability to
detect emotion-specific reactivity in BPD. Although
research provides support for the relevance of these
emotions in particular to BPD [11,26,27,31,32,37], future
studies should examine other emotions as well, such as
dysphoria, loneliness, and/or worthlessness (see reference
[62]). Furthermore, although the computerized nature of
this study limited interactions between experimenters and
participants (thereby reducing the extent to which experi-
menters may have inadvertently influenced participants'
performance), masked assessments would have further
decreased the potential for experimenter biases and should
be used in future studies. Finally, due to our experimental
design, this study examined reactivity to negative evalua-
tion only after exposure to a general stressor. As a result,
findings may not generalize to emotional reactivity to
negative feedback in the absence of a prior stressor. Future
studies should examine if exposure to a previous stressor
and/or the presence of general emotional distress influences
emotional responding to negative feedback among indivi-
duals with BPD.
Future studies also would benefit from the use of
physiological measures of emotional responding (such as
heart rate variability and electrodermal response), as well as
the inclusion of biological measures of emotional reactivity
(eg, fluctuations in cortisol levels throughout the experi-
mental procedure). In providing a more objective assessment
of emotional responding, the use of such measures would
assist in determining whether differences in emotional
reactivity and recovery among individuals with BPD (vs
those without BPD) are the result of actual physiological or
biological differences in emotional responding or simply
differences in how individuals with BPD respond to and
Moreover, future research should examine the influence
of participants' emotion regulation strategies during the
laboratory session on emotional responding. For example,
the use of dissociation or other emotionally avoidant
regulation strategies in response to the laboratory stressors
(likely more common among the BPD participants; see
references [2,63,64]) may have resulted in lower emotional
reactivity to these stressors, limiting our power to detect
between-group differences in emotional reactivity and
delayed recovery. Future studies should specifically assess
and control for participants' reported regulation strategies
during the stressors on emotional responding throughout
the session. Furthermore, although neither rates of use nor
number of psychiatric medications differed between groups
and results did not change when controlling for psychiatric
medications, medications likely influence emotional arousal
and reactivity is a variety of ways. Thus, the wide
variability in the use of medications within the groups
284 K.L. Gratz et al. / Comprehensive Psychiatry 51 (2010) 275–285
complicates interpretation of our results. Research is
needed to explore more rigorously the impact of medication
use on emotional reactivity and recovery among individuals
with and without BPD.
Despite limitations, the results of this study suggest that
individuals with BPD may be emotionally reactive (and, as a
result of the magnitude of their emotional reactions, evidence
a delay in their return to baseline levels of emotional arousal)
in the context of specific emotions (eg, shame) and specific
cues (eg, negative evaluation). Findings in the extant
literature pertaining to emotional reactivity in BPD may be
obscured by the reliance on broad-based examinations of
general emotional reactivity without consideration of the
contexts that differentially elicit emotional responses and the
specific emotional states that characterize emotional reactiv-
ity. Our findings of emotion-specific and context-dependent
reactivity demonstrate the importance of continuing to
examine reactivity across specific emotions and in response
to particular stressors to better understand the nature and
extent of subjective emotional reactivity in BPD. Results of
this study also highlight the relevance of shame to BPD,
providing preliminary evidence for shame-specific reactivity
in BPD and suggesting the importance of assessing for the
presence of this emotion among BPD patients in clinical
settings. Furthermore, these findings have potential clinical
implications, suggesting the potential utility of targeted
interventions for BPD aimed at decreasing shame [28].
Acknowledgment
This research was supported by a grant from the
Psychosocial Foundation of McLean Hospital awarded to
the first author. The authors wish to thank Donna Lacroce for
her assistance in data collection.
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