Emotional Regulation and Affects in Patients With Borderline Personality Disorder

Background: The regulation of emotions and affective strategies have been shown to be relevant in the clinic of borderline personality disorder (BPD), however, the studies carried out are still not conclusive on the inuencing role of these two variables on the course of the TLP. The need for empirical evidence on the relationship between the internal components of these manifestations is faced: cognitive reappraisal, expressive suppression, positive affect and negative affect. Result: The results indicate that the psychological variables studied present more dysfunctional values in patients with BPD. The symptomatic of BPD does not moderate the relationship between cognitive reappraisal and negative affect; and cognitive reappraisal together with positive affect are associated with fewer BPD symptoms. Conclusion: The results obtained offer different clinical implications in the affective and emotional context of BPD, however, it would be necessary to use alternative measures of the emotional pattern, such as physiological methodologies to have more dening results.


Introduction
Borderline personality disorder (BPD) is a persistent pattern characterized by marked emotional instability and lack of impulse control that signi cantly affects interpersonal relationships. The age of onset of symptoms is usually at the beginning of adulthood, at which time the subjects manifest behaviors such as: repeated efforts to avoid situations of abandonment (real or imagined), unstable behavior in social relationships, alterations self-identity (both in terms of self-image and sense of self), impulsive behaviors (which can become reckless), affective instability with sudden mood swings, chronic thoughts and feelings of emptiness, di culties to control emotions, and even paranoid ideation associated with states of stress and / or severe dissociative symptoms (American Psychiatric Association, APA, 2013).
In relation to the prevalence and incidence data, epidemiology places frequency rates within the range 0.2-1.8% in the general population of developed countries (APA, 2013). It is also known that BPD is the cause of hospital admission in a high percentage of patients, and that in psychiatric care units this disorder can be identi ed in almost 50% of admitted patients. Available data also indicate that this disorder occurs more frequently in women, with a ratio that can reach 3: 1 (APA, 2013; Skodol & Bender, 2003). This differentiation by sex should, however, be taken with caution, since some professionals indicate that the real incidence in men may be underestimated due to their greater resistance to receiving psychological care (Briscoe, 1987 Emotional regulation is a complex construct that includes internal and external mechanisms responsible for identifying, analyzing, and modifying emotional reactions according to contextual demands, in order to provide optimal responses and satisfactorily meet the proposed goals (Thompson 1994). It involves cognitive, physiological and behavioral aspects (Gross & Jazaieri, 2014;Scherer, Schorr & Johnstone, 2001). Gross's model of emotional regulation maintains that regulation strategies can be explained based on two basic mechanisms: cognitive reappraisal referring to the mental construction of the situation, focused on the "antecedent" of the emotion) and Expressive suppression (referred to the modulation of the response, focused on the inhibition of the expressive behavior of the current emotion) (Gross, 2002;Gross & John, 2003).
It has been found that, in comparison with healthy controls, patients with BPD tend to show differences in the degree of cognitive reappraisal they perform of situations. Speci cally, the presence of this disorder causes a poorer expression of cognitive elaboration, which would be the basis for the subsequent expression of more dysfunctional responses in emotional regulation (Koenigsberg et al., 2019). But these results may not be speci c, since relevant differences have not always been observed when BPD is compared with other psychiatric disorders (attention de cit disorder; major depressive disorder; post- Regarding the emotional states of BPD, there is a large number of studies in this area that relate the disorder with affectation in two dominant dimensions: positive affect and negative affect (Conklin, Bradley & Westen, 2006;Jacob et al., 2011;Sadikaj et al., 2010). Positive affect refers to the experience of characteristics related to satisfaction, good humor, security, or enthusiasm (generators of pleasant states). Negative affect refers to aversive emotional characteristics, such as nervousness, fear, disgust, guilt or anger (generators of emotional distress). In global terms, it is known that people with BPD tend to present instability in affect (Trull et al., 2008;Zittel-Conklin & Westen, 2005), probably as a consequence of di culties in recognizing, differentiating and processing their own emotions. Ultimately, the consequences of this instability are usually impulsive actions that can become self-injurious and / or heterolesive (Berlin, Rolls & Iversen, 2005;Westen, 1991).
In healthy people, aspects of emotional regulation, cognitive reappraisal and expressive suppression have been related to positive and negative affects (Gross & John, 2003). On the other hand, in patients with LPD, the psychological aspects of negative affect and expressive suppression have been investigated (Salsman & Linehan, 2012), highlighting important interrelations between the characteristics of BPD, emotional regulation and negative affective intensity. Speci cally, considering that, in healthy people, the regular use of cognitive reappraisal strategies has been related to greater positive affect, better interpersonal functioning and greater well-being in general, and that, on the contrary, expressive suppression is It has been associated with a greater presence of negative affect, that is, a greater number of depressive symptoms and less success in recovering mood (Gross & John, 2003;Haga, Kraft & Corby, 2009 The present study arises from the need to have empirical evidence on the psychological manifestations and characteristic symptoms of BPD. The knowledge about the development of these psychological characteristics attached to the emotional and affective determinant, will make it possible to support the direct and predictive effects, as well as the interrelationships that involve the discernment of BPD. Previous studies in this area have been limited by their inability to use comprehensive measures among these psychological manifestations. Therefore, the main objective of this study is to compare measures of cognitive (re) evaluation, expressive suppression, positive affect and negative affect between patients with a diagnosis of BPD and controls. Based on the data published in the available literature, it is hypothesized that: H1) BPD symptoms moderate the relationship between (re) evaluation and negative affect; and H2) cognitive reappraisal has less relationship on the symptoms of BPD, when positive affect is controlled.
The results obtained in the study have an implication in the eld of evaluation and intervention in patients with BPD. Knowing better what the interrelationships are between these aspects will help to design measuring instruments with greater discriminatory capacity and more precise treatment programs between these dimensions.

Participants
The study sample included a total of n = 70 participants who voluntarily agreed to take part in the Three relevant characteristics were considered as inclusion criteria for the BPD and control group: a) being over 18 years of age; b) know how to read; c) have a normal vision or corrected to normal. For its part, only the BPD group took into account two more characteristics: meeting DSM-5 criteria for BPD and not presenting an acute psychotic episode. Sandín et al., (1995). It consists of 20 words that describe different feelings and emotions, and where the evaluated person must indicate using a scale of ve values to what extent they experience each of these emotions (active, strong, inspired, for example). The scale is structured in two subscales that measure positive affect and negative affect. In this study made up of the Ecuadorian population, it has adequate psychometric indices, with a reliability of 0.90 for positive affect and 0.93 for negative affect (Cronbach's alpha coe cients).

Instruments Positive Affectivity and Negative Scale (PANAS) by Watson, Clark & Tellegen (1988), Spanish Version by
Emotion Regulation Questionnaire (ERQ) by Gross & John, (2003). Spanish version of Cabello et al., (2013). It is a questionnaire with a self-report format that assesses two emotion regulation strategies: cognitive reappraisal (6 items) and expressive suppression (4 items . Scale with a self-report format that assesses the level of BPD symptoms. It includes a total of 23 items evaluated on a 5-point Likert scale, ranging from 0 (none) to 4 (very strong). Provides a one-dimensional total score (within the range of 0 to 92 points). Higher scores indicate a higher level of severity for borderline symptoms. The present study has a reliability of 0.95 (Cronbach's alpha coe cient).
In addition to the previous questionnaires, three questions referring to sociodemographic information were collected: sex, chronological age and educational level (primary, secondary and professional).

Procedure
The research had bioethical authorization for the investigation by the Ministry of Public Health of Ecuador. The study was carried out using a non-experimental cross-sectional design.
The data collection was carried out by the research group of the Laboratory of Basic Psychology, Behavior Analysis and Programmatic Development of the Catholic University of Cuenca. The research was carried out following the principles of the Declaration of Helsinki and the APA research code (APA, 2002, Barnett & Johnson, 2008;Behnke, 2006). The participants gave their informed consent in writing for their data to be part of the research.
For data collection, the patients underwent the session at the hospital center and the controls at home or in the laboratory facilities. The procedure included the signing of the informed consent, the collection of demographic data, the retrieval of data from the medical history (patients only), the social perception task, and the lling in of the scales.

Analysis of data
In the development of the study objective, the T-Test was used, which allows to compare means obtained in independent samples and the Pearson r correlation analysis that allows to see the degree of association between variables. Multiple linear regression models were applied to test the two hypotheses (H1 and H2). All the models reported in this work ful ll the assumptions of linearity, independence, homoscedasticity, normality and non-collinearity.
The computer programs to calculate the database were: R software version 3.6.1 (Ihaka & Gentleman, 1996) and JASP software version 9.2.0. (Love et al., 2018).

Results
Description of the participants Table 1 presents the distribution of the sociodemographic variables of the study in each group, as well as their statistical comparison. These data indicate that there are no statistically signi cant differences between the sociodemographic variables and the study groups. Comparison of the groups in clinical variables. Table 2 presents the distribution of the psychological variables of the study in each group, as well as their statistical comparison. These data indicate that there are statistically signi cant differences between both groups in the dimensions of: BPD symptomatology, cognitive (re) evaluation, expressive suppression, positive affect and negative affect. Association between the clinical variables of the study Table 3 contains the correlation matrix for the study variables, strati ed by the diagnostic group (the upper part presents the R coe cients for the BPD group and the lower part for the control group). In patients with BPD, it is observed that:

Analysis of moderation of BPD symptoms in the relationship between cognitive reappraisal and negative affect
As can be seen from the data of the model that includes the interaction parameter (Model 1) that appear in Table 4, cognitive reappraisal is not signi cantly associated with negative affect, however, the symptoms of BPD are on the other hand, the interaction parameter is not statistically signi cant (B = 0.001, p = 0.959), therefore it is excluded from the analysis. According to the model without interaction (Model 2), increasing cognitive reappraisal by one point implies a decrease of between 0.417 and 0.052 in negative affect; For its part, although the symptoms of BPD do not moderate this relationship, it acts as a signi cant predictor, indicating that increasing the symptoms of BPD by one point implies an increase between 0.191 and 0.318 in negative affect. Study between cognitive reappraisal and BPD symptoms adjusted for positive affect Table 5 presents the linear regression model that measures the degree to which positive affect may be acting as a confounding variable between the relationship between cognitive reappraisal (independent variable) and BPD symptoms (dependent variable). The results of the initial model (block 1) and the model with the control variable (block 2) are presented. The initial step indicates that the relationship between the cognitive reappraisal and the symptoms of BPD is signi cant. The results of adding in the second step of positive affect indicate that the adjusted contribution of the cognitive reappraisal is B = − 0.904, an effect that continues to be signi cant (p < 0.01). Since the difference between the adjusted and the unadjusted parameter is greater than 10%, we consider that the contribution of the model with the control variable of the results correctly re ects the contribution of the cognitive reappraisal.

Discussion
The present study proposed as a general objective to obtain new empirical evidence on the development of the psychological manifestations of BPD, in aspects related to emotional regulation [cognitive reappraisal and expressive suppression] and affects. Speci cally, its purpose was to examine potential relationships between cognitive (re) evaluation, expressive suppression, positive affect, negative affect and the symptoms of BPD.
Regarding the study objective, the BPD group presented differences in the study variables, with clearly more dysfunctional values in clinical patients compared with healthy subjects, which is consistent with the results obtained in previous studies ( Regarding the rst hypothesis, the results reveal that the symptoms of BPD do not moderate the relationship between cognitive reappraisal and negative affect. The data indicate that the higher the cognitive (re) evaluation, the lower the negative affect. This relationship is similar to the results described by Gross and John (2003)  . Therefore, this result supports that cognitive reappraisal in conjunction with positive affect can be denoted as characteristics associated with less BPD symptoms. Important data because it strengthens information, since in this study both positive affect and cognitive reappraisal were considered simultaneously, appreciable characteristics in the disorder (Conklin, Bradley & Westen, 2006;Sadikaj et al., 2010;Trull et al., 2008).

Limitations
The results of this study should be interpreted considering a set of limitations. First, all variables in the study were assessed using self-report measures. The use of behavioral and physiological measures in future research can help to further expand the knowledge of the relationships between these variables by having a measurement from an observable organic value. In addition, this study worked with crosssectional data. Longitudinal data can help clarify the relationships between these variables from an evolutionary perspective, speci cally the data collected from repeated measurements over long periods of time, will allow contrasting the changes and provide a deep explanation of the proposed hypotheses, especially in the function moderator of BPD symptomatology and the confounding role of positive affect, as well as the comparison of measures between both study groups. In particular, ambulatory monitoring, as well as laboratory studies, can be used to examine real-time data on affects, emotion regulation, and the characteristics of BPD. On the other hand, despite the fact that the statistical calculation of the second hypothesis was carried out with caution (e.g. compliance with assumptions), in this study the sample size or post hoc power was not calculated to calculate the effect of cognitive (re) evaluation,

Implications
The results obtained have different clinical implications. On the one hand, they provide knowledge about the characteristics of BPD and its explanatory mechanisms. Knowledge about the emotional and affective performance of the disorder can be used as a theoretical-empirical basis for the development of ad hoc assessment instruments that facilitate e cient diagnostic screening, and for the development of psychotherapeutic intervention plans focused on the speci c needs of the course. of the disorder, with the purpose of improving the functionality and quality of life of the patient. On the other hand, the mixed sample (control-BPD) apart from being advantageous in the study for representing a complete range of values marking group differences, makes it possible to have a solid representation of these psychological manifestations in the clinical diagnosis, because it provides a basis to elucidate the affective and emotional substrates of BPD that contribute to the explicit determination of the disorder.

Conclusions
In global terms, the results of this study deepen efforts to investigate the role of the elements of emotional regulation in conjunction with the affects (positive and negative) denoted as central characteristics of BPD. The psychological variables studied presented clearly marked more dysfunctional values in BPD patients; on the other hand, the symptoms from BPD do not moderate the relationship between cognitive reappraisal and negative affect, which had been previously described in healthy people; and, nally, the cognitive reappraisal in conjunction with positive affect can be denoted as relevant characteristics in the decrease in the symptoms of BPD. Authors 'contributions GGRO was responsible for the study design, data collection, and data analysis. DOIA was responsible for the literature review and development of the introduction. Both authors contributed to the analysis and discussion of the ndings. Both authors read and approved the nal manuscript.

Funding
No funding.

Availability of data and materials
Please contact GGRO for data request.
Ethical approval and consent to participate

Consent for publication
Not applicable.

Competing interests
The authors declare that they have no competing interests.