Journal of

Experimental Psychopathology
JEP Volume 4 (2013), Issue 5, 584599
ISSN 2043-8087 / DOI:10.5127/jep.030312

Affective Disturbance and Psychopathology: An Emotion

Regulation Perspective
Hooria Jazaieri, M.A.a, Heather L. Urry, Ph.D.b, & James J. Gross, Ph.D.a
a

Stanford University, Department of Psychology, Stanford, CA, United States

Tufts University, Department of Psychology, Medford, MA, United States

Abstract
It is widely thought that many psychological disorders involve emotion dysregulation. However, it is not yet clear
just how many of the disorders presented in the Diagnostic and Statistical Manual of Mental Disorders-IV-Text
Revision (DSM-IV-TR) are formally characterized by emotion regulation difficulties and related affective
disturbances. To address this issue, we first define emotion, emotion regulation, emotion dysregulation, and
affective disturbance. Next, we systematically code the psychological disorders listed in the DSM-IV-TR in terms of
the presence or absence of affective disturbance and emotion dysregulation. We then use an emotion regulation
perspective to examine affective disturbances in Axis II disorders, with a focus on borderline personality disorder
(BPD). Finally, in the last section, we discuss some of the implications of our emotion regulation perspective for
clinical assessment and intervention.
Copyright 2013 Textrum Ltd. All rights reserved.
Keywords: affective disturbance; emotion regulation; emotion dysregulation; psychopathology; DSM; borderline
personality disorder
Correspondence to: Hooria Jazaieri, Stanford University, Department of Psychology, 420 Jordan Hall, Room 430,
Stanford, CA 94305-2130, United States. Email: hooria@stanford.edu
1. Stanford University, Department of Psychology, 420 Jordan Hall, Room 430, Stanford, CA 94305-2130, United
States
2. Tufts University, Department of Psychology, 490 Boston Avenue, Room 043, Medford, MA 02155
Received 27-Jun-2012; received in revised form 06-Dec-2012; accepted 06-Dec-2012

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Table of Contents
Introduction
Emotion, Emotion Regulation, Emotion Dysregulation, and Affective Disturbance
Emotion and Other Affective Processes
Emotion Regulation and Other Forms of Affect Regulation
Emotion Regulation, Emotion Dysregulation, and Affective Disturbance
Affective Disturbance in the DSM-IV-TR
Coding of the DSM-IV-TR
Affective Disturbance and Emotion Dysregulation in DSM-IV-TR
Affective Disturbance and Emotion Dysregulation on Axis II: The Case of Borderline Personality Disorder
Situation Selection
Situation Modification
Attentional Deployment
Cognitive Change
Response Modulation
Implications for Assessment and Treatment
Clinical Assessment
Clinical Interventions
Concluding Comment
References

Introduction
It is commonly said that emotion dysregulation characterizes more than half of the mental disorders described in
the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 1994; Barlow,
2000; Kring & Sloan, 2010; Kring & Werner, 2004; Werner & Gross, 2010). This observation fits nicely with the idea
that the regulation of emotions is an essential component to mental health (Gross & Muoz, 1995). The empirical
record, however, is far thinner than these broad claims would suggest. In this article, we use an emotion regulation
perspective to clarify the role of affective disturbance in psychopathology.
Specifically, we begin by defining emotion, emotion regulation, emotion dysregulation, and affective disturbance. In
the second section, we systematically code 176 mental disorders in the DSM-IV-TR for the presence of affective
disturbance and emotion dysregulation. In the third section, we use an emotion regulation perspective to examine
affective disturbances in Axis II disorders, with a focus on borderline personality disorder (BPD). Finally, in the
fourth section, we discuss implications of this perspective for clinical assessment and clinical intervention,
specifically within the context of dialectical behavior therapy (DBT).

Emotion, Emotion Regulation, Emotion Dysregulation, and Affective

Disturbance
Many terms are used to refer to emotion and emotion-related processes, and a consensus has yet to emerge
regarding precise definitions of these terms. Therefore, it is useful to be explicit about how one conceptualizes
emotion and related terms (Gross, 2010).

Emotion and Other Affective Processes

Core features of emotion include situational antecedents, attention, appraisal, and multifaceted response
tendencies (Werner & Gross, 2010). First, emotions involve an activating event. Emotions do not just land on us
like fairy dust, but instead begin with an internally or externally relevant situation. Second, emotions require
attention. We must attend to a potentially emotion-eliciting situation for emotion to arise. However, it is important to
note that this attention may not involve conscious awareness. Third, situations must be appraised for emotions to
arise. Here too, it is important to note that this appraisal may not be conscious. Fourth, emotions prompt action

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urges and in many cases, actual expressive behaviors. Emotions are multi-faceted processes which include
subjective experience, behavior, and physiology (central and peripheral) (Mauss, Levenson, McCarter, Wilhelm, &
Gross, 2005).
Defined in this way, emotions are one type of affective response. We conceive of affect as an overarching term that
includes emotions, moods, and stress responses (Gross & Thompson, 2007). Affect involves an evaluation that
something is good or bad for one in light of currently active goals. Affective states unfold over time and vary in
quality, magnitude (intensity), duration, and frequency. Emotions may be distinguished from other affective
processes, albeit imperfectly, by noting that they are typically briefer than moods, and comprise a broader range of
responses than are typically included within the rubric of the stress response.

Emotion Regulation and Other Forms of Affect Regulation

Emotion regulation refers to influencing the particular emotions one has, when one has them, and how these
emotions are (or in some cases, are not) experienced and/or expressed (Gross, 1998b). At times, the goal of
altering the emotion trajectory represents an end in itself in these cases, the motivation to regulate is driven by
directly wanting to change one or more emotions. In other cases, altering the emotion trajectory simply serves as a
means to an end in these cases, the motivation to regulate is driven by some other goal (Gross & Thompson,
2007).
Three core features of emotion regulation deserve emphasis. First, one may regulate negative or positive emotions
by either decreasing or increasing their magnitude or duration. Second, emotion regulation can be a conscious,
intentional process, or a process that occurs without conscious awareness (Gross & Thompson, 2007). Third,
emotion regulation processes cannot be said to be all good or all bad, as the specific context determines
whether emotion regulation is helpful in a specific context in light of ones current goals.
Emotion regulatory processes can be organized into groups based on when they have their primary impact on the
emotion-generative process (Gross, 1998a; Figure 1). In particular, we have distinguished among five specific
families of emotion regulation processes: situation selection, situation modification, attentional deployment,
cognitive change, and response modulation. Situation selection refers to efforts to influence emotion, either by
increasing or decreasing the likelihood of encountering a given situation where particular emotions are likely
elicited. Situation modification refers to efforts to alter ones emotions by changing external, physical features in the
environment. Attentional deployment refers to efforts to alter ones emotions by directing ones attention in a
particular way in a given situation. Cognitive change refers to efforts to alter ones emotions by changing the
meaning of the situation. Lastly, response modulation refers to efforts to alter ones physiological, experiential, or
behavioral responses. While these distinctions are useful, it is important to note that in everyday life, it is common
to engage in behaviors than represent amalgams of different strategies.
It is important to note that aside from emotion regulation, there are many other forms of affect regulation including
mood regulation and coping. These forms correspond to each of the distinctions we drew in the last section among
affective processes, so that affect regulation refers broadly to the regulation of any affective state, mood regulation
refers to attempts to regulate mood, and coping refers to efforts to regulate some component of a stressful
situation. In terms of affect regulation, in this paper we focus only on emotion regulation and emotion dysregulation
and its relation to broader affective disturbance (for a more detailed description of the other forms of self-regulation
see Gross & Thompson, 2007).

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Figure 1: Process model of emotion regulation that highlights five families of emotion regulation strategies (Gross &
Thompson, 2007; re-printed with permission by Guilford Press).

Emotion Regulation, Emotion Dysregulation, and Affective Disturbance

When emotion regulation goes well, the individual successfully regulates his/her emotion(s) and goes on his/her
merry way. However, when emotion regulation does not go well, emotion dysregulation occurs, which we can
define as a state in which despite an individuals best efforts, regulatory attempts are not achieving the individuals
emotion related goal(s) and the individual is unable to make necessary corrections to achieve the emotion related
goal(s). There are numerous factors that may produce emotion dysregulation. For example, emotion dysregulation
may occur when the emotion regulation strategy employed is problematic or maladaptive in some way (e.g.,
creates more of the very emotion s/he is trying to regulate, creates a problematic secondary emotion, etc.).
Emotion dysregulation has been closely tied to psychopathology, particularly mood and anxiety disorders (e.g.,
Cole, Michel, & Teti, 1994).
We define affective disturbance as a disruption in the multi-system response (subjective experience, expressive
behavior, physiology) of emotions, moods, and stress responses. Affective disturbance can refer to either negative
affective states (e.g., anxiety or depression) or positive affective states (e.g., euphoria or mania). One prominent
cause of affective disturbance may be difficulties with emotion regulation. From this perspective, then, emotion
regulation and potential subsequent emotion dysregulation are subordinate to the broader construct of affective
disturbance. Further, emotion regulation is neither good nor bad, while emotion dysregulation and affective
disturbance are by definition considered to be dysfunctional states.

Affective Disturbance in the DSM-IV-TR

Many of the disorders described in the Diagnostic and Statistical Manual of Mental Disorders (DSM; American
Psychiatric Association, 1994) are said to include some sort of affective disturbances, some of which may result
from emotion dysregulation (Gross, Sheppes, & Urry, 2011). Indeed, affective disturbances are thought to be
important features of psychopathology some diagnostic disorders are defined primarily in terms of disturbed
emotions (Mineka & Sutton, 1992), and a failure to regulate intense, negative, and shifting emotional states
(Bradley et al., 2011). However, many other disorders do not seem to feature such difficulties as prominently in
their diagnostic criteria.

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To our knowledge, previous research has not empirically determined the presence of affective disturbances and
emotion dysregulation in the DSM. Using an approach that reflects current thinking in affective science, we set out
to quantify the extent to which the criteria for Axis I and II diagnoses in the DSM-IV-TR involve affective disturbance
and emotion dysregulation. Thus, we developed a coding scheme that incorporates the major points of consensus
regarding the key features of affect and its regulation.

Coding of the DSM-IV-TR

The coding system we developed captures affective disturbance as explicitly represented (or not) in the formal
diagnostic criteria for DSM-IV-TR disorders. For a disorder to be included, its entry in DSM-IV-TR needed to
include a formal set of diagnostic criteria (e.g., Diagnostic Criteria for Mental Retardation). The only information
used to code affective disturbances associated with each diagnosis was that presented in the formal criteria sets,
and not information provided in Introduction, Diagnostic Features, Associated Features and Disorders, Specific Age
and Gender Features, Prevalence, Course, Familial Features, etc. Although affective information may be present in
these supplemental sections, this information was not considered to be a defining feature of the diagnosis and was
thus excluded. We excluded diagnoses listed as Other Conditions That May Be a Focus of Clinical Attention as
well as diagnoses listed in Appendix B, Criteria Sets and Axes Provided for Further Study. We acknowledge that
diagnoses listed in these sections involve affective disturbance (e.g., V62.82 Bereavement), but we excluded them
to narrow our focus to official diagnostic categories. These criteria led to the identification of 176 diagnoses for
coding (see Supplemental Materials).
Three PhD-level psychologists independently coded all 176 diagnoses. Two coders (HLU and JJG), both trained as
clinical psychologists, initially coded 21 diagnoses to create a gold standard. Upon establishing this standard, all
diagnoses were coded by the three independent raters. Interrater reliability (Cohens kappa) between the gold
standard and the third coder was computed on the basis of the independent codes for all 176 diagnoses. Kappas
indicated acceptable interrater reliability (mean = .79, minimum = .45, and maximum = .95). The final codes
used in the analyses reported here were determined by consensus.
For each set of criteria, we made 20 coding decisions. The first captured the extent of affective disturbance
reflected in the diagnosis. This was coded using a 4-point scale ranging from 0, no affective disturbance, to 3, in
which receiving the diagnosis guarantees affective disturbance. Next, we coded whether there was evidence of
negative affective (NA) disturbance and/or positive affective (PA) disturbance. A 3-point scale was used for each of
these two decisions. A 0 was assigned when there was no NA or PA. A 1 was assigned when there was an
indication of a state that might reflect NA or PA, but it was unclear, and a 2 was assigned when there was definitely
NA or PA present. Where possible, we further distinguished between the intensity, duration, and frequency of NA
and PA experience, and separately, between the intensity, duration, and frequency of NA and PA expression.
Codes were assigned to one or more of the three experience columns when it was clear that the person carrying
the diagnosis was presumed to feel the emotions/moods noted in the criteria with some specifiable level of
intensity, duration, or frequency. Codes were assigned to one or more of the three expression columns when it was
clear that a reasonable observer would see the affective states described (or the criteria indicated that it was
observable to others) with some specifiable level of intensity, duration, or frequency. Intensity was noted when an
explicit qualifier indicated that the experience or expression of NA and/or PA was too intense (e.g., marked) or too
weak (e.g., deficient), or when an affect term was deemed inherently intense or weak by definition (e.g.,
depressed was interpreted to be an intense state of sadness, and loss of temper, which was interpreted to be an
intense state of anger). Duration was noted when an explicit qualifier indicated that the experience or expression of
NA and/or PA lasted too long (e.g., persistent) or too short. Frequency was noted when an explicit qualifier
indicated that the experience or expression of NA and/or PA was too frequent (e.g., often) or too infrequent. For
all of these, a 0 was assigned without an explicit qualifier.
In addition to the experience and expression of affective disturbance, we noted the presence of putatively affectrelated autonomic physiological changes. Here, we keyed in on terms that clearly indicated the presence of
autonomic physiological changes (e.g., tachycardia, sweating) when affective disturbance was also present.
Somatic symptoms such as muscle tension, psychomotor agitation or retardation, and headaches that were
suggestive of autonomic physiological changes were considered maybe responses, as were terms such as

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psychomotor agitation or retardation or feeling keyed up. Presence of physiological symptoms in the absence of
affective disturbance was coded as absent.
We also assessed whether each criteria set contained information suggesting a problem of emotion regulation (ER)
(i.e., emotion dysregulation). Scores were assigned on a 3-point scale (0, no problem with ER noted, 1, ER may be
present but this conclusion is somewhat speculative, and 2, yes, there is a problem of ER). Issues of emotion
dysregulation were often expressed in terms of avoidance of situations that prompt NA (e.g., taking a substance to
relieve withdrawal symptoms that include anxiety, or avoiding situations in which one has previously experienced a
panic attack). On occasion, an inability to control affect was noted explicitly. The inability to control non-affective
behaviors was not considered evidence of emotion regulation and was therefore assigned a code of 0.
We coded the presence of affective lability and clinically significant distress. Affective lability reflected the degree to
which affective/mood lability is a symptom (0 = no, 2 = yes). For this decision, the criteria must explicitly indicate
that there is affective lability. Where lability is not explicitly noted, an inference of lability was warranted only when
there is some explicit indication of the time frame for cycling between affective states, which should be reasonably
short. In addition, there must have been an explicit indication that affect is shifting between positive and negative
states (i.e., if it remained possible that affect is shifting between emotions within the positive or within the negative
domain, then affective lability was coded 0). The presence of affective lability did not imply an issue of intensity,
duration, or frequency unless there were appropriate qualifiers. However, when affective lability was coded as
present, we also assigned a code of present to NA and PA disturbance.
Lastly, we noted when the disorder included a statement somewhere indicating that the symptoms of the disorder
may be characterized by clinically significant distress (0 = no, 2 = yes) (e.g., The symptoms in Criterion B cause
clinically significant distress or impairment in social, academic, or occupational functioning.). This statement could
occur as its own separate criterion or as part of another criterion, and could be present even in disorders for which
there were no affective disturbance otherwise represented in the criteria. Disorders that only indicated that the
symptoms must incur clinically significant impairment in social, academic, or occupational functioning were coded
as absent because we were specifically attempting to capture distress.

Affective Disturbance and Emotion Dysregulation in DSM-IV-TR

We computed basic frequencies to determine the percent of times each code appeared across the 176 diagnoses.
Key findings are as follows: 1) Affective disturbance is likely present in 40.3% of these diagnoses, and is
guaranteed in 19.3% of them. Examples of disorders where affective disturbance was likely present include
oppositional defiant disorder (313.81) and hypochondriasis (300.7). Disorders where affective disturbance was
guaranteed include separation anxiety disorder (309.21) and anorexia nervosa (307.1). 2) This affective
disturbance is typically on the negative side of the valence dimension (39.2%) rather than the positive side, but
positive affective disturbance is still relatively frequent (19.3%; note: the NA and PA percentages do not sum to
40.3% since some diagnoses have disturbance at both ends of the valence dimension). Examples of disorders
where affective disturbance appeared only on the negative side include dysthymic disorder (300.4) and sleep terror
disorder (307.46). Examples of disorders where affective disturbance appeared on both the negative and positive
side include histrionic personality disorder (301.50) and posttraumatic stress disorder (309.81). 3) Across Axes,
emotion dysregulation is either implied (6.8%) or definitely (14.8%) present in 21.6% of the 176 diagnoses we
surveyed. Examples of implied emotion dysregulation include bipolar II disorder (296.89) and panic disorder
without agoraphobia (300.01). Examples of definite emotion dysregulation included dependent personality disorder
(301.6) and pathological gambling (312.31). 4) Finally, clinically significant distress is a criterion for 58% of
disorders including major depressive disorder (296.2x) and obsessive compulsive disorder (301.4). (For full coding
decisions for all 176 disorders, please see Supplemental Materials).
Overall the results of our coding indicate that although a large portion of descriptions of disorders contain a likely
presence of affective disturbance (40.3%), far fewer descriptions of disorders than previously assumed include
specific mention of affective disturbance in the DSM-IV-TR. Less than a quarter (21.6%) of descriptions of
disorders in the DSM-IV-TR actually have some sort of definite or implied problem of emotion regulation. These
results point to an important gap that exists between DSM-IV-TR diagnostic criteria and clinical understanding

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(informed by the scientific literature as well as clinical intuition) of these disorders. It is important to parse out which
aspects of the two representations of mental disorders DSM diagnostic criteria versus clinical understanding
best reflect reality.

Affective Disturbance and Emotion Dysregulation on Axis II: The Case of

Borderline Personality Disorder
To illustrate the value of assessing affective disturbance and emotion dysregulation in DSM disorders, we highlight
for more detailed consideration one Axis II disorder, namely borderline personality disorder (BPD). Affective
disturbance is pervasive across Axis II disorders and is often exacerbated by high levels of comorbidity with Axis I
disorders (e.g., Pfohl, Black, Noyes, Coryell, & Barrash, 1991; Widiger et al., 1991). Among Axis II disorders, BPD
is unequivocally considered to be the prototypical disorder of affective disturbance. Therefore, through the
examination of BPD as a case study, we next examine affective disturbance in relation to the five families of
emotion regulatory processes.
BPD has a lifetime prevalence rate of 1-5.9% (Grant et al., 2008; Samuels et al., 2002; Swartz, Blazer, George, &
Winfield, 1990; Torgersen, Kringlen, & Cramer, 2001), lifetime suicide attempt rates over 70% (Soloff, Lynch, &
Kelly, 2002; Soloff, Lynch, Kelly, Malone, & Mann, 2000; Zisook, Goff, Sledge, & Shuchter, 1994), and typically, at
least one concurrent Axis I disorder (e.g., Zimmerman & Mattia, 1999). BPD is characterized by pervasive patterns
of unstable affective states, interpersonal relationships, and self-image (American Psychiatric Association, 1994).
These patterns begin in early adulthood and persist in varying contexts and environments.
The diagnostic features of BPD include affective, cognitive, behavioral, and interpersonal disturbances. An
individual with BPD experiences at least five out of nine features: 1) displays of frantic behaviors in an attempt to
avoid abandonment (actual or perceived); 2) patterns of intense and unstable interpersonal relationships with
others, often altering between idealization of the person to complete devaluation; 3) identity disturbance, wherein
the person persistently lacks a clear sense of self or experiences an unstable self-image; 4) impulsivity in two or
more potentially self-damaging areas such as excessive spending, reckless driving, binge eating, substance abuse;
5) recurrent suicidal ideations, behaviors, gestures, or communication, or other self-harm or self-mutilating
behavior; 6) affective instability due to reactive mood states ranging from irritability, anxiety, or dysphoria, which
last between a few hours to a few days; 7) ongoing feelings of emptiness; 8) intense and often inappropriate
displays of anger and general difficulties controlling anger; or 9) occasional (stress-related) paranoid thinking or
severe dissociative symptoms.
According to Linehan (1987), emotion dysregulation lies at the core of BPD. In particular, BPD is said to be caused
by both a biological vulnerability to emotion dysregulation (a high baseline negative emotional intensity coupled
with high emotional reactivity that is activated when encountering an emotion evoking situation) and an invalidating
environment (Linehan, 1993a). On this view, emotion dysregulation is a significant contributor to the overarching
affective disturbance that is pervasive in BPD. As Linehan (1993a) states, suicidal and other impulsive,
dysfunctional behaviors are usually maladaptive solution behaviors to the problem of overwhelming, uncontrollable,
intensely painful negative affect (p. 60).
Utilizing the coding procedures described in the previous section, according to the formal diagnostic criteria for
BPD, there is a guaranteed affective disturbance characterized by negative affect, a general problem of emotion
regulation, and clinically significant distress. The negative affect problem featured in the diagnostic criteria for BPD
is characterized by a problem of intensity, duration, and frequency of negative affect expression and by a problem
of intensity and frequency of negative affect experience. Findings for BPD are summarized in Table 1. In the
following sections, we consider BPD in more detail, focusing on each of the five families of emotion regulation
processes specified by the process model of emotion regulation.

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Table 1: Coding of Affective Disturbance and Difficulties with Emotion Regulation of Borderline Personality Disorder
in the DSM-IV-TR
Axis II: 301.83 Borderline Personality Disorder
Affective disturbance?

Guaranteed

NA?

Definitely present

PA?

Not present

NA expression:
Intensity?

Yes

Duration?

Yes

Frequency?

Yes

Intensity?

Yes

Duration?

No

NA experience:

Frequency?

Yes

PA expression:
Intensity?

No

Duration?

No

Frequency?

No

Intensity?

No

PA experience:
Duration?

No

Frequency?

No

Autonomic physiological changes?

No

Problem of ER?

Yes

Affective lability?

No

Clinically significant distress?

Yes

Specific emotions?

Affective instability; dysphoria; irritability; anxiety; emptiness; anger

Note. NA = Negative Affective; PA = Positive Affective; ER = Emotion Regulation

Situation Selection
In BPD, situation selection can be compromised due to states described as active passivity or apparent
competence (Linehan, 1993a). In active passivity, the individual behaves in a passive and helpless manner,
rather than in an active and determined one. Thus, the individual will often avoid the situation that may evoke an
unwanted emotion and instead look to others in the environment for solutions (Linehan, 1993a). On the other hand,
when in a state of apparent competence, the individual at times appears competent and able to skillfully cope with
everyday life tasks (and chooses to engage in situations that may evoke certain emotions), and at other times, will
behave as if the competencies do not exist (Linehan, 1993a) and will not engage in these situations in order to
avoid unwanted emotions. Thus, situation selection (in the context of active passivity or apparent competence) can
lead to affective disturbance; however in BPD, the inverse is also true, affective disturbance can also lead to
situation selection. For example, when individuals with BPD are experiencing heightened emotional reactivity, the
ability to properly weigh short-term versus long-term benefits and consequences of engaging in particular situations
is compromised. Because behavior in BPD is often mood- or emotion-dependent, the individual may proceed with
approaching or avoiding a situation based on current emotional state, examining the prompting event or situational
antecedents only in relation to the emotion currently being experienced, rather than considering the broader
context. As Linehan (1993a) states, failures to inhibit maladaptive, mood-dependent action are by definition part of
the borderline syndrome (p. 43). To date to our knowledge, there has not been any explicit empirical research
conducted with those with BPD who endorse the perception of active passivity or apparent competence.

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Situation Modification
For those with BPD, the very emotion (and expression of that emotion) that they are experiencing can modify a
situation. For example, in an invalidating environment, the emotions of the person with BPD are often dismissed;
therefore, in an effort to better communicate an emotion to those in the environment, the person with BPD may
escalate (or up-regulate) the expression of that (typically negative) emotion. Such up-regulation of the emotional
response is an instance of response modulation (discussed below). However, such up-regulation also may be
considered an instance of situation modification when this escalation successfully gets the attention of those in the
environment, causing them to suddenly take interest in the BPD individuals emotions (and experience) in a caring
way (positive reinforcement; Skinner, 1953) and thus, modifying the previous situation. Over the longer term, this
can be problematic because those in the environment are inadvertently reinforcing the escalation of emotion, and
thus increasing the likelihood that the escalation of emotion as a means of communicating will reoccur. Essentially,
the individual with BPD has learned that on some level, the escalation of ones emotion and related features can be
an effective way to communicate to others because the original invalidating response from the environment is
consequently modified into a validating and caring one. Therefore, it makes sense that individuals with BPD can
proficiently intensify the valence and arousal of negative stimuli as well as prolong the duration of the effect of the
stimulus (Putnam & Silk, 2005, p. 900), as this response is learned to be an effective way of communicating with
those in the environment following invalidation. To date to our knowledge, there has not been any explicit empirical
research examining the role of environmental reinforcement on emotion and emotional expression in individuals
with BPD.

Attentional Deployment
Individuals with BPD tend to use distraction and rumination. One form of maladaptive distraction that is employed
by individuals with BPD is dissociation. In BPD, severe dissociation is reported when stress levels are high
(Stiglmayr et al., 2008). It is possible that the maladaptive attentional deployment through dissociation precipitates
the self-injurious behavior that is prevalent in BPD (Gratz, Conrad, & Roemer, 2002). Because 50-60% of those
who engage in self-injurious behavior report that no pain is felt (Kleindienst et al., 2008), it is possible that
dissociation or attentional deployment is taking place during the self-harm behavior, and thus pain is not
experienced. Distraction may also be combined with rumination, as when individuals with BPD focus on a
secondary feature of a situation so as to minimize one emotion while possibly maximizing another emotion. For
example, if an individual has just gotten fired for being late to work again, the primary emotion may be anxiety
about finding another job and paying bills. For most, anxiety is an uncomfortable emotion to experience. Thus,
attentional deployment (e.g., in the form of rumination) may kick in as the person recounts the many times when
she came into work early and stayed late, and after some time, she may no longer feel anxiety about finding a new
job or paying bills, but is now irate about getting fired. Rumination here refers to perseverating on ones feelings
and the consequences of those feelings (or behaviors or action urges associated with the feelings).

Cognitive Change
In general, it has been noted that the later an emotion-regulatory process occurs, the more likely it is to be affected
by the level of emotional intensity (Sheppes & Gross, 2011, p. 323). For those with BPD, it is difficult to employ
cognitive change strategies such as reappraisal because frequently, by the time they consider using this strategy,
the emotion is often already too intense and distressing (Putnam & Silk, 2005). This is problematic because those
with BPD have a poor assessment of their abilities to effectively deal with intense emotional stimuli (Putnam & Silk,
2005) and therefore may choose to simply not use any regulation strategies with intense emotions, perpetuating
heightened emotional reactivity. In an fMRI study of cognitive reappraisal in BPD, Schultze and colleagues (2011)
found that when attempting to downregulate negative emotional responses while viewing negative aversive stimuli,
cognitive reappraisal skills were not implemented in women with BPD. Further, poor cognitive change abilities lead
to enduring, inflexible, and dichotomous thinking (Wenzel, Chapman, Newman, Beck, & Brown, 2006), which may
contribute to the primarily-negative experiences that are readily recalled to memory rather than more neutral or
positive ones in BPD (Donegan et al., 2003; Korfine & Hooley, 2000; Kurtz & Morey, 1998).

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Response Modulation
Response modulation can take many different forms in BPD including self-injurious behavior, or other maladaptive
behaviors such as binge eating, and excessive consumption of alcohol, prescription or non-prescription drugs. As
Linehan (1993a) states, borderline patients are so fearful of emotions, especially negative ones, that they try to
avoid them by blocking their experience of the emotions. (p. 345). Of these, self-injurious behavior is one of the
most common forms of response modulation, with prevalence rates of up to 84% (Clarkin, Widiger, Frances, Hurt,
& Gilmore, 1983; McGlashan et al., 2005). Self-injury is defined as a direct and intentional injury of body tissue,
without suicidal intent (Klonsky, 2007). Clinically and theoretically, self-injurious behavior serves an important
function (Connors, 1996a, 1996b; Linehan, 1993a). Consistent with the experiential avoidance model (Chapman,
Gratz, & Brown, 2006), self-injurious behavior is seen as a means of providing relief from unwanted emotions (e.g.,
Gratz et al., 2002). Further, it has been noted that self-injurious behavior is associated with an inability to verbally
express ones emotions (Zlotnick, Donaldson, Spirito, & Pearlstein, 1997), and self-injury has been noted to be
more prevalent in individuals who have a lower capacity to tolerate strong emotions (Deiter, Nicholls, & Pearlman,
2000). Self-injurious behavior is reinforced by relief from negative emotions (Nock & Prinstein, 2004). The
reinforcement from oneself and the environment (in the form of caretaking behavior) are powerful in maintaining
self-injurious behavior. The function of self-injurious behavior as a method of suppressing an emotional experience
in order to escape painful or overwhelming emotions suggests an obvious deficit in adaptive emotion regulation
skills.

Implications for Assessment and Treatment

Our emotion regulation perspective has implications for clinical assessment and how we might move beyond the
current edition of the DSM. Further, this perspective also has implications for existing and future clinical
interventions that address emotion dysregulation across disorders. It is our belief that only through more fine-tuned
assessment can ecologically-valid interventions for affective disturbance and emotion dysregulation emerge.

Clinical Assessment
It is a widely-held belief that many mental disorders involve emotion dysregulation. However, based on our coding,
less than a quarter of the DSM-IV-TR disorders have some sort of definite or implied problem of emotion regulation.
At the same time, approximately 40% of disorders are likely to exhibit some sort of affective disturbance (typically
negative). Although this number seems relatively low, given the likelihood of comorbidity among Axis I and Axis II
disorders in the Diagnostic and Statistical Manual of Mental Disorders, it is likely that the occurrence of affective
disturbance and difficulties with emotion regulation are much higher in typical clinical presentations (given that the
probability of affective disturbance when more than one disorder is present is higher and perhaps much higher
than 40%).
Others have stressed that although clinicians conceptions of disorders and the descriptions in the DSM overlap,
there are also systematic differences whereby clinician conceptions place greater emphasis on the patients
mental life and inner experiences (Shedler & Westen, 2004). Shedler and Westen (2004) have suggested that the
DSM-IV criterion sets are too narrow. They do not capture the richness and complexity of personality syndromes
as they are understood by clinicians in the community, observed empirically in patients treated in the community, or
defined by DSM-IV itself (p. 1359). Again, this suggests that the features highlighted in the diagnostic criteria for
DSM-IV-TR are perhaps only a subset of the actual features observed in a clinical setting.
In the proposed DSM-V revision, there are promising substantial changes whereby using a hybrid dimensionalcategorical model for personality disorders has been suggested (American Psychiatric Association, 2012). The
dimensional assessments will include ratings of personality pathology severity according to the Levels of
Personality Functioning. Two scales will be assessed, one assessing self functioning and another assessing
interpersonal functioning. Both will be evaluated on a continuum ranging from no impairment, i.e., healthy
functioning (Level = 0) to extreme impairment (Level = 4).

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Self functioning is examined in terms of identity (experience of oneself as unique, with clear boundaries between
self and others; stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range
of emotional experience) and self-direction (pursuit of coherent and meaningful short-term and life goals;
utilization of constructive and pro-social internal standards of behavior; ability to self-reflect productively) are
evaluated. Interpersonal functioning is examined in terms of empathy (comprehension and appreciation of others
experiences and motivations; tolerance of differing perspectives; understanding of the effects of own behavior on
others) and intimacy (depth and duration of positive connections with others; desire and capacity for closeness;
mutuality of regard reflected in interpersonal behavior.).
For borderline personality disorder, proposed DSM-V revisions include requiring both A) significant impairments in
self functioning, and interpersonal functioning, and B) pathological personality traits including negative affectivity
(e.g., emotional lability, anxiousness, etc.), disinhibition, and antagonism (American Psychiatric Association, 2012).
While these revisions seem promising due to the inclusion of more references to difficulties with affective
disturbance and emotion dysregulation, it is necessary for the continued consideration of more dimensional
accounts of psychopathology for all disorders in order to more fully encompass the clinical realities that patients
and therapists face. Further, it is our hope that particular attention will paid to examining the presence of emotion
regulatory difficulties and affective disturbance when conceptualizing criteria for pathology. More specifically, it will
be important to broaden the criteria for disorders beyond symptoms to empirically based descriptions of the
mechanisms that underlie the onset or maintenance of these symptoms of affective disturbance and emotion
dysregulation.

Clinical Interventions
Many have emphasized the importance of emotions in treatment (Greenberg & Safran, 1987; Mennin, Heimberg,
Turk, & Fresco, 2002; Safran, 1998; Samoilov & Goldfried, 2000). Examining components of affective disturbance
such as maladaptive emotion regulation attempts may be key to better understanding disorders and assisting in
enhancing treatments to target these areas. Emotion dysregulation is considered by some to be a multidimensional
construct which involves: a) lack of awareness, understanding, and/or acceptance of emotions; b) lack of access to
adaptive strategies for modulating the intensity and/or duration of emotional responses; c) an unwillingness to
experience emotional distress in order to pursue desired goals, and d) an inability to engage in goal-directed
behaviors when experiencing distress (Gratz & Roemer, 2004). In addition to determining the factors that give rise
to emotion dysregulation, it is also important to examine what other factors may lead to the heightened emotional
reactivity that is evident in psychopathology.
Our analysis of BPD suggests that emotion regulatory attempts are being made; however, these attempts are not
necessarily moving the individual towards his or her goals and are often creating significant problems. It is likely
that across other disorders, emotion regulatory attempts are also being made, albeit unsuccessfully. These
maladaptive strategies may be factors contributing to the clinical presentation.
As highlighted by our coding, affective disturbance is present across axes in the DSM, thus, many therapies have
been designed to target affective disturbance and emotion dysregulation. Formal treatment programs and
interventions that explicitly address affective disturbance and emotion dysregulation by way of emotion regulation
skills include Dialectical Behavior Therapy (DBT; Linehan, 1993a), Emotion-focused therapy (EFT; Greenberg,
2002), Unified Protocol for the Treatment of Emotional Disorders (Barlow, Allen, & Choate, 2004), Emotion
Regulation Therapy (ERT; Mennin, 2004; Mennin & Fresco, 2009), and Integrative Training of Emotional
Competencies (ITEC; Berking, 2007). These programs have been implemented with clinical and non-clinical
populations as a method of enhancing emotion regulation. Informal programs have also been implemented
including an affect and interpersonal regulation training (Cloitre, Koenen, Cohen, & Han, 2002), a
psychoeducational group training program which includes topics of emotion recognition and emotion management
(Clyne & Blampied, 2004), and an integrative acceptance-based emotion regulation training as an adjunct to
treatment as usual (Gratz & Gunderson, 2006). More recently, mindfulness-based interventions have been linked
with improvements in emotion regulation skills (e.g., Arch & Craske, 2006; Blackledge & Hayes, 2001; Goldin &
Gross, 2010; Robins, Keng, Ekblad, & Brantley, 2012; Roemer, Erisman, & Orsillo, 2009). Mindfulness, or
intentionally paying attention in the present moment, can be thought of as a form of attentional deployment.

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However, unlike most traditional emotion regulation interventions which aim to down-regulate negative emotions,
mindfulness practice (as it applies to emotions, at any rate) seeks to create distance between the person and the
emotion by allowing one to observe emotions as being separate from oneself and not evaluating the emotion
(meta-thoughts regarding emotions) in any way (Corcoran, Segal, Anderson, & Farb, 2009).
Given our case study emphasis on BPD, here we will focus on the most common intervention for this disorder,
Dialectical Behavior Therapy (DBT; Linehan, 1993a). DBT is considered to be the gold-standard or best practice
treatment for BPD; here, we will focus on aspects of DBT (for borderline personality disorder) that assist in
enhancing emotion regulation. Dialectical behavior therapy was originally created for individuals with borderline
personality disorder (Linehan, 1993a); however, preliminary evidence has since noted its effectiveness in the
treatment of various other disorders including substance abuse (Linehan et al., 2002), eating disorders (Safer,
Telch, & Agras, 2001; Telch, Agras, & Linehan, 2001), and depression in older adults (Lynch, Morse, Mendelson, &
Robins, 2003). In DBT, emotion dysregulation is considered to be a Stage I problem as emotion dysregulation is
typically paired with severe behavioral dyscontrol. In Stage I of treatment, the goal is to gain behavioral control
through learning skills.
It has been noted that those at risk for developing BPD exhibit an oversensitive emotion generative system that is
highly sensitive to emotional stimuli and that produces an intense response that is slow to return to emotional
baseline (Linehan, Bohus, & Lynch, 2007), thus, the emotion regulation component of DBT treatment is primarily
response-focused. For example, after checking the facts of the emotion and situation, the individual decides
whether to act on the action urge associated with the emotion, or to act opposite to emotional urges (Linehan,
1993b, in press). This opposite action might include approaching a situation even when experiencing intense fear
or avoiding a situation when experiencing intense anger. Further, individuals learn to examine whether an emotion
is effective and congruent with ones goals as a method of assisting in choosing to follow action urges associated
with the emotion or to inhibit unskillful action urges. Attentional deployment in the form of dissociation is specifically
targeted in DBT in several ways. Dissociation is treated as a problem behavior that is tracked on weekly diary
cards. Further, through functional chain analyses, the patient and therapist analyze the prompting events and
antecedents of the behavior in order to gain insight into its occurrence. More broadly, the patient learns emotion
regulation and distress tolerance skills in order to better cope with stressful situations and crises that may prompt
dissociation. Further, in individual therapy, the patient may work on becoming desensitized to cues to past
traumatic experiences that may prompt negative emotions and dissociative behavior (Bohus et al., 2004; Linehan,
1993a, in press). Self-injury or self-harm behavior, a form of response modulation, is addressed in a similar fashion
to dissociation where the behavior is tracked, analyzed, and replaced with a more skillful behavior (e.g.,
mindfulness of current emotions or utilizing distress tolerance for very intense emotions).
Skills for reducing vulnerability to emotion mind (or amygdala hijack) prior to emotion onset are also discussed in
the emotion regulation module. Patients learn to actively accumulate positive emotions by intentionally scheduling
pleasant events, build mastery in activities that make one feel accomplished and competent, cope ahead of time for
potential situations that will bring about strong emotions, and take care of ones body by treating physical illnesses,
eating well, avoiding mood altering drugs, getting sufficient sleep and regular exercise (Linehan, 1993b, in press).
Further, skills deficits in cognitive change are informally addressed throughout each skills module (Linehan,
1993a). However, cognitive change must be coupled with validation, and a structured cognitive change procedure
is often not appropriate for most individuals with BPD as it requires preliminary skills before successful
implementation (Linehan, 1993a).
Because most individuals are unaware of the actual processes involved in emotion dysregulation and are instead
typically concerned with the symptom (or the consequences of the problem behavior), one way that DBT addresses
this issue is through utilizing a detailed chain analysis of the problematic behavior. In the chain analysis, the
individual examines the vulnerability factors (e.g., forgot to take medication, only got three hours of sleep, etc.),
prompting event (e.g., boyfriend didnt return text message, colleague didnt say hello to me, etc.), links (what
occurred between the prompting event and the problem behavior, e.g., actions, bodily sensations, cognitions,
events, feelings), problem behavior (often the symptom of the disorder, e.g., engaging in self-harm behavior,
yelling, etc.), and consequences (immediate and delayed consequences in the individual and the environment as a
result of the problem behavior). The goal of a chain analysis is to assist the individual with gaining insight into the

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processes involved in the problematic behavior (which is typically a symptom of the disorder or playing a role in
maintenance of the disorder).

Concluding Comment
Although interventions for specific populations exist to address different types of affective disturbance, the findings
from our coding of the DSM point to the importance of emotion regulation skills training across a variety of forms of
psychopathology. Effectively using emotion regulatory strategies has important implications for mental health and
well-being. Future research should examine the effectiveness of existing treatments in improving emotion
regulation and identify whether such improvements are important mechanisms of change. Further, future studies
may consider examining treatment outcomes of treatment as usual (TAU) verses TAU paired with emotion
regulation skills training. In addition, although not captured within our coding of the DSM, emotion regulation skills
training may be beneficial at a much broader level, regardless of current mental health status or psychopathology.
Because emotions are an integral part of everyday life, in an effort to optimize one's ability to function at the highest
possible level, future research may benefit from examining the potential benefits of emotion regulation skills training
among healthy adults or those who do not necessarily meet DSM criteria for psychopathology.

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