A Comparison of Self-Reported Emotional Regulation Skills in Adults With Attention-Deficit/Hyperactivity Disorder and Borderline Personality Disorder

Abstract

Objective: Emotion dysregulation has been described as a central feature of both borderline personality disorder (BPD) and attention-deficit/hyperactivity disorder (ADHD). The current study aims to compare emotion regulation among ADHD, BPD, and healthy controls (HC). Method: Eighty adults with ADHD, 55 with BPD, and 55 HC completed self-report assessments of ADHD and BPD symptoms, psychosocial functioning, and emotion regulation skills. Principal components analysis (PCA) was conducted on the emotion regulation items, followed by multivariate analyses of group differences in emotion regulation. Results: PCA yielded four components: “Being Aware of Emotions,” “Making Sense of Emotions,” “Modifying and Accepting Emotions,” and “Confronting Emotions With Self-Encouragement.” The last component best distinguished the two patient groups from the HC. No differences were found between adults with ADHD and BPD. Conclusion: Adults with ADHD and BPD report comparable difficulties in encouraging oneself to attend inner aversive experiences, without engaging in impulsive behavior.

Keywords

ADHD borderline personality disorder emotional dysregulation experiential avoidance psychiatry

Introduction

Emotion regulation consists of the extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions to accomplish one’s goals (Thompson, 1994). According to Berking and Znoj (2008), adaptive emotion regulation requires the interaction of several skills: (a) paying attention to emotional processes, (b) recognizing and labeling emotions, (c) correctly interpreting emotion-related physiological changes, (d) identifying triggers of emotions, (e) actively modifying emotions in quality and intensity, (f) accepting emotions, (g) tolerating emotions, (h) supporting oneself in emotionally distressing situations to retain impulsive behaviors, and (i) confronting emotionally distressing situations if necessary to achieve personal goals. Emotion dysregulation occurs when an individual is unable to exercise any or all of these skills to such an extent that it causes suffering and functional impairment (Bunford, Evans, & Wymbs, 2015).

Emotion dysregulation is a dimensional trait, rather than a categorical diagnosis, that is likely to be implicated as an etiological factor in a wide range of psychopathological symptoms (Shaw, Stringaris, Nigg, & Leibenluft, 2014). It has been found to be associated with various mental disorders (Berking & Wupperman, 2012), including borderline personality disorder (BPD) and attention-deficit/hyperactivity disorder (ADHD). Indeed, some authorities have conceptualized BPD to be a disorder of primary emotion dysregulation. They propose that emotion dysregulation emerges from interactions between biological vulnerabilities and environmental influences, and engenders dysregulation in other areas such as interpersonal relationships, behavior control, identity, and cognition (Crowell, Beauchaine, & Linehan, 2009). Current research (Carpenter & Trull, 2013; van Zutphen, Siep, Jacob, Goebel, & Arntz, 2015) indicates that people with BPD show difficulties in recognizing and labeling emotions, as well as facing and tolerating distress when pursuing goals. Furthermore, people with BPD have been found to employ a lack of appropriate regulation strategies, and to have a tendency to choose maladaptive strategies. These maladaptive strategies might have an immediate effect on negative emotions, but are ultimately problematic due to negative consequences or noneffectiveness in the long term (e.g., rumination, thought suppression, experiential avoidance, suicidal and self-injurious behaviors, eating disorders, impulsive buying, substance use).

Recently, the Diagnostic and Statistical Manual of Mental Disorders (DSM) ADHD criteria of inattention, hyperactivity, and impulsivity have been criticized as being insufficient in describing the full nature of this disorder in adults. Emotional dysregulation has been proposed to be an additional significant feature of ADHD in adulthood (Bunford et al., 2015; Corbisiero, Stieglitz, Retz, & Roesler, 2013; Graziano & Garcia, 2016; Martel, 2009; Shaw et al., 2014). According to Reimherr and colleagues (2005), emotion dysregulation in adult ADHD presents as temper control (“feelings of irritability and frequent outbursts of short duration”), affective lability (“shifts from normal mood to depression or mild excitement”), and emotional overreactivity (“diminished ability to handle typical life stresses, resulting in frequent feelings of being hassled and overwhelmed”, p. 125). Emotion dysregulation has been found to occur in up to 70% of adults with ADHD (Shaw et al., 2014); to be more frequent in people diagnosed with the combined inattentive and hyperactive-impulsive representation (Reimherr, Marchant, & Olson, 2010); to be a marker of severity of ADHD (Corbisiero, Moerstedt, Bitto, & Stieglitz, 2016); to contribute to suicidal ideation (Van Eck et al., 2015); to be associated with higher levels of comorbid disorders (including personality disorders; Reimherr, Marchant, Williams, et al., 2010); and to be an independent source of functional impairments in people with ADHD (Faraone et al., 2015; Moerstedt, Corbisiero, Bitto, & Stieglitz, 2016). A recent meta-analysis of emotion regulation in youth with ADHD found a medium effect (Cohen’s d = 0.64) for the association between ADHD and the ability to recognize and understand emotions, and a large effect (d = 0.80) for the association between ADHD and the ability to modulate emotional responses (Graziano & Garcia, 2016).

The occurrence of emotion dysregulation in both BPD and ADHD complicates the task of differential diagnosis and raises questions about the nature of the relationship between the two disorders. In studies of adults with ADHD, BPD has been reported to co-occur in up to 27% of clinical and 63% of forensic samples, is most common in patients with the combined (inattentive and hyperactive-impulsive) ADHD presentation, and occurs more frequently among females than males (Matthies & Philipsen, 2014). Likewise, some studies have reported that approximately 38% of adults with BPD have comorbid ADHD and up to 60% meet criteria for ADHD in childhood (Asherson et al., 2014; Matthies & Philipsen, 2014). Adults with comorbid ADHD and BPD might represent a particularly severe subgroup, with studies reporting greater rates of mental state and personality pathology, aggression, impulsivity, and psychosocial impairments, compared with those reported in adults with either ADHD or BPD alone (Ferrer et al., 2010; O’Malley, McHugh, Mac Giollabhui, & Bramham, 2015; Philipsen et al., 2008; Prada et al., 2014). Notably, among females, Fossati et al. (2015) found a significant association between retrospectively assessed childhood ADHD and adult BPD, which was fully mediated by emotion dysregulation and impulsivity. This finding is supported by other research demonstrating that ADHD is a childhood precursor to BPD features in adolescence and adulthood (Carlotta, Borroni, Maffei, & Fossati, 2013; Chanen & Kaess, 2012; Stepp, Burke, Hipwell, & Loeber, 2012; Storebo & Simonsen, 2014; van Dijk, Lappenschaar, Kan, Verkes, & Buitelaar, 2011).

Despite the above evidence, to date, only two studies have directly compared emotion dysregulation in ADHD and BPD. Witt, Brucher, Biegel, Petermann, and Schmidt (2014) compared 58 adults with ADHD, 37 with BPD, 19 with BPD plus ADHD, along with a clinical and a nonclinical control group using two measures, the ADHD-screening for adults (Schmidt & Petermann, 2013) and the scale for the assessment of impulsivity and emotion dysregulation of BPD (Kröger & Kosfelder, 2011). They found significantly higher levels of emotion dysregulation in the BPD group, compared with the ADHD group. Philipsen et al. (2009) compared 60 adults with ADHD, 60 with BPD, and 60 healthy controls (HC) using the Borderline Symptom List (BSL; Bohus et al., 2007). Significantly higher scores were reported on the Emotion Regulation subscale for BPD than for ADHD participants. Notably, in both studies, emotion dysregulation was assessed (a) with a measure developed to capture either ADHD or BPD symptomatology, and (b) as a single construct, thereby neglecting distinguishable processes involved in emotion regulation. Thus, the current study aims to further explore emotion regulation in adults with ADHD, compared with adults with BPD and with HC, using a questionnaire specifically developed to assess various emotion regulation skills, independent of psychopathological symptoms. In accordance with recent research, we hypothesized that adults with BPD would report lower levels of emotion regulation competencies than adults with ADHD (Hypothesis 1; Philipsen et al., 2009; Witt et al., 2014). In addition, we expected both patient groups to report lower levels of emotion regulation competencies than HC (Hypothesis 2; Berking & Znoj, 2008).

Method

Participants and Study Procedure

The current study was nested within a randomized controlled trial of treatment for ADHD, led by the last author. Recruitment took place in Switzerland between 2013 and 2015. Eighty-nine ADHD participants were recruited from the ADHD Special Consultations Unit of the Outpatient Department, University of Basel Psychiatric Clinics. Inclusion criteria were age between 18 and 65 years and a Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) ADHD diagnosis. Exclusion criteria were insufficient command of German, intellectual disability, lifetime diagnosis of schizophrenia or another psychotic disorder, and a current or recent episode of mania, severe major depression, acute stress disorder, or substance dependence. In accordance with current guidelines (National Institute for Health and Care Excellence [NICE], 2008), ADHD diagnoses were made by two independent experts on the basis of clinical interviews, self-rating and observer-rating scales, developmental and psychiatric history, and the examination of school certificates and/or reports from former teachers, when available. The diagnostic interviews included the Wender–Reimherr Adult Attention Deficit Disorder Scale (Wender, 1995), and the Adult Interview by Barkley and Murphy (1998). The short version of the Wender Utah Rating Scale (Retz-Junginger et al., 2002) was used for the retrospective assessment of childhood ADHD symptoms. Current ADHD symptoms were assessed by the Self-Report and Observer-Rating of the Conners’ Adult ADHD Rating Scales (CAARS-SR/-O; Conners, Erhardt, & Sparrow, 1991).

Fifty-five BPD participants were recruited from the University of Basel Psychiatric Clinics, and the University Hospital of Psychiatry and Psychotherapy Bern. Inclusion criteria were age between 18 and 65 years, and an International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10; World Health Organization, 1993) BPD diagnosis. Exclusion criteria were insufficient command of German, IQ <85, and severe disturbance, such that the person was unable to comply with either the requirements of informed consent or study procedure. Diagnoses were made through a thorough psychiatric evaluation and screening of medical records by trained clinical psychologists and psychiatrists during treatment as usual.

Fifty-five control participants were staff from the University of Basel Psychiatric Clinics, friends and acquaintances of the authors, and students from the University of Basel. Inclusion criteria were age between 18 and 65 years, and no current or past psychiatric disorder. Participants with insufficient command of German were excluded. HC were matched in terms of age and gender to the ADHD group.

All participants were informed by a member of the study team about the aims, risks, benefits, and procedure of the study, and gave written informed consent. Following this, they underwent an assessment of about 45 to 60 min to answer a set of self-report measures. The study was approved by local ethics committees.

Measures

The long version of the CAARS-SR (Christiansen et al., 2013) was used to assess for current ADHD symptom severity. It includes 66 items that are rated on a 4-point Likert-type scale (0 = not at all or never to 3 = very much or very frequently). The subscales Inattention/Memory Problems, Hyperactivity/Restlessness, Impulsivity, Emotional Lability, and Self-Concept Problems were constructed by averaging corresponding items, with higher scores indicating higher symptom severity. Internal consistencies of the subscales in the current study were excellent, with Cronbach’s alpha = .86 to .91.

The short version of the Borderline Symptom List (BSL-23; Bohus et al., 2009) was used to assess for current BPD symptom severity. It includes 23 items that are rated on a 5-point Likert-type scale (0 = not at all to 4 = very strong) with regard to the past week. A total score was calculated by averaging the items, with a higher score indicating higher symptom severity. Cronbach’s alpha in the current study was .96, indicating excellent internal consistency.

The Barkley Functional Impairment Scale–Long Form (BFIS-LF) is a self-report measure of major domains of psychosocial functioning in adults (Barkley & Fischer, 2010). It includes 15 items that are rated on a 10-point Likert-type scale (0 = not at all to 9 = totally) with regard to the past 6 months. The total score was constructed by averaging all items, with a higher score indicating more severe functional impairments. Internal consistency in the current study was acceptable, with Cronbach’s alpha = .72.

The Emotion Regulation Skills Questionnaire (ERSQ; Berking & Znoj, 2008) was used to assess perceived emotional regulation skills in the past week. It includes 27 items, rated on a 5-point Likert-type scale (0 = not at all to 4 = almost always), which can be pooled into a total score or nine subscales reflecting different aspects of emotion regulation, as described above. Good convergent and discriminant validity were reported by the authors (Berking & Znoj, 2008), indicating that the constructs assessed with the ERSQ do not merely reflect psychopathological symptoms, but rather aspects of emotion regulation. In the current study, Cronbach’s alpha was .76 for the total score, and ranged between .74 and .92 for the subscales, indicating adequate internal consistency.

Statistical Analyses

Only core statistical analyses are reported here. Additional information is given in supplementary materials. All analyses were conducted using SPSS Version 23 (IBM Corp., 2013).

Of the 198 participants, eight were excluded from data analysis because they were diagnosed with both ADHD and BPD, resulting in N = 190. For descriptive purposes, the ADHD, BPD, and HC groups were compared in terms of gender, age, years of education, ADHD and BPD symptom severity, and psychosocial functioning (see Supplementary Material A for further information).

A principal components analysis (PCA) was performed on all 27 items of the ERSQ used in the current samples of ADHD and BPD patients, to reduce the large number of variables into a smaller number of components, and to test the original scale structure, established in a study of patients with affective, anxiety, and somatoform disorders (Berking & Znoj, 2008). Because the emotion regulation skills underlying ERSQ items are thought to be correlated (Berking & Znoj, 2008), oblique rotation was used. For comparison purposes, PCA was repeated with orthogonal (varimax) rotation (Tabachnick & Fidell, 2007d). Emotion regulation component scores for each individual were computed by averaging raw scores that corresponded to all items loading on each extracted component (DiStefano, Yhu, & Mindrila, 2009).

To analyze mean differences among groups on the combined emotion regulation components, two separate one-way between-subjects MANOVAs with the emotion regulation components as dependent variables and the grouping variable as independent variable were performed. The first MANOVA contrasted ADHD and BPD patients (Hypothesis 1), and the second MANOVA contrasted patients (ADHD, BPD) and HC (Hypothesis 2). Wilks’s Λ was used to test significance of the main effect of the grouping variable (Tabachnick & Fidell, 2007c).

Although the MANOVA emphasizes the mean differences among groups on the combined dependent variables, the discriminant analysis (DA) can be used to further investigate and interpret the number and nature of dimensions on which the groups differ (Tabachnick & Fidell, 2007b). A one-way between-subjects direct DA with the four emotion regulation components as predictors of group membership (ADHD, BPD, HC) was conducted (Tabachnick & Fidell, 2007b). Notably, in the MANOVA, the emotion regulation components were used as dependent variables and the grouping variable as predictor, whereas in the DA, the grouping variable was used as the dependent variable and the emotion regulation components as predictors. In addition, to determine which single emotion regulation component is most helpful for separating the BPD patients from the ADHD patients (Hypothesis 1), and the patient groups from the HC (Hypothesis 2), a series of separate ANCOVAs were conducted, with each emotion regulation component as the dependent variable and the remaining emotion regulation components as covariates. In each ANCOVA, contrasts were only interpreted if the main group effect was significant after family-wise error adjustment was applied to reduce the danger of inflation of Type I error rate when performing multiple tests (Tabachnick & Fidell, 2007b).

Results

Table 1 displays the demographic and clinical characteristics of the study sample. Participants with ADHD, participants with BPD, and HC significantly differed in gender, years of education, ADHD and BPD symptom severity, and psychosocial functioning, but not in age. The majority of participants with BPD were female. In contrast, the majority of participants with ADHD and HC were male. Post hoc pairwise comparisons revealed that HC reported more years of education than participants with ADHD (p < .001) who, in turn, reported more years of education than participants with BPD (p < .01). Participants with ADHD showed higher levels of inattention (p < .001), hyperactivity (p < .01), and impulsivity (p < .01) than participants with BPD, who, in turn, reported higher symptomatic levels than HC (p < .001). In contrast, participants with BPD reported more self-concept problems (p < .001), general borderline symptomatology (p < .001), and functional impairments (p < .05) than participants with ADHD, who, in turn, showed higher levels of psychopathology and functional impairments than HC (p < .001). Both participants with ADHD and participants with BPD showed higher levels of emotional lability than HC (p < .001), but no significant differences were found between participants with ADHD and participants with BPD (p = .81). The group differences in ADHD and BPD symptom severity and psychosocial functioning remained significant (p < .05), after considering gender and years of education as covariates. In sum, the differences found in symptomatology between ADHD, BPD, and HC support the diagnostic validity of the groups.

Table 1.

Demographic and Clinical Variables of the Study Sample (N = 190).

	ADHD (n = 80)	BPD (n = 55)	HC (n = 55)	Group comparisons
	M (SD)/n (%)	M (SD)/n (%)	M (SD)/n (%)	Group comparisons
Gender (m/f)	50/30 (62.5/37.5)	2/53 (3.6/96.4)	30/25 (54.5/45.5)	χ²(2) = 50.13***
Age	33.39 (9.4)	30.11 (10.24)	33.33 (11.56)	F(2, 187) = 1.95
Years of education	11.75 (2.23)	(n = 52) 10.35 (2.7)	13.63 (3.26)	Welch’s F(2, 103.55) = 16.05***
CAARS-SR Inattention/Memory Problems	1.85 (0.57)	(n = 54) 1.44 (0.51)	0.61 (0.44)	Welch’s F(2, 119.12) = 106.76***
CAARS-SR Hyperactivity/Restlessness	1.72 (0.60)	(n = 54) 1.30 (0.69)	0.62 (0.38)	F(2, 113.69) = 89.89***
CAARS-SR Impulsivity	1.65 (0.59)	(n = 54) 1.22 (0.70)	0.54 (0.41)	Welch’s F(2, 114.10) = 85.66***
CAARS-SR Emotional Lability	1.81 (0.65)	(n = 54) 1.79 (0.60)	0.56 (0.53)	F(2, 186) = 83.46***
CAARS-SR Self-Concept Problems	1.71 (0.72)	(n = 54) 2.20 (0.64)	0.63 (0.58)	F(2, 186) = 81.60***
BSL-23	1.23 (0.74)	(n = 54) 2.12 (0.99)	0.22 (0.22)	Welch’s F(2, 96.29) = 148.08***
BFIS	5.03 (1.75)	6.43 (3.54)	1.40 (1.60)	Welch’s F(2, 105.45) = 94.48***

Note. BPD = borderline personality disorder; HC = healthy controls; CAARS-SR = Conners’ Adult ADHD Rating Scale–Self-Report; BSL-23 = Borderline Symptom List–Short Version; BFIS = Barkley Functioning Impairment Scale.

***

p < .001.

Before running the PCA, the 27 ERSQ items were analyzed with regard to missing data and outliers, resulting in a reduction of the total sample to n = 188. Four components with Eigenvalues greater than 1 were extracted. Comparing results from both oblique and orthogonal (varimax) rotations, an inspection of the correlation matrix revealed numerous correlations above .32, which indicates 10% (or more) overlap in variance among components, enough variance to warrant oblique rotation (Tabachnick & Fidell, 2007d). In addition, oblique rotation resulted in a simpler structure, with several variables correlating highly with each component and only one component correlating highly with each variable. Therefore, the oblique rotation solution is reported here. All variables demonstrated loadings of .32 and above and, thus, were involved in the interpretation of the components (Tabachnick & Fidell, 2007d). The first component showed high loadings for all items included in the original subscales Resilience, Acceptance, and Regulation (Berking & Znoj, 2008), and was labeled “Modifying and Accepting Emotions.” The second component, which incorporated the items of the Awareness subscale (Berking & Znoj, 2008), was titled “Being Aware of Emotions.” The third component included all items of the subscales Bodily Sensations, Clarity, and Understanding (Berking & Znoj, 2008), and was named “Making Sense of Emotions.” Finally, the fourth component, which combined the subscales Willingness to Confront Oneself and Self-Support (Berking & Znoj, 2008), was called “Confronting Emotions With Self-Encouragement.” The component scores created by averaging all items loading on a component showed excellent internal consistencies, with Cronbach’s alphas of .93, .78, .91, and .92, respectively. See Supplementary Material B for additional information to the PCA.

The emotion regulation components were tested for univariate or multivariate outliers, reducing the total sample to n = 186. Given the group differences found in demographic characteristics (see Table 1), the multivariate significance test of group differences in emotion regulation components was conducted with adjustment for gender and years of education as covariates (MANCOVA). Contrasting ADHD and BPD patients (Hypothesis 1), the main effect of the grouping variable on the emotion regulation components was nonsignificant, with Wilks’s Λ F(4, 126) = 0.98, p = .75. Contrasting the two patient groups (ADHD, BPD) and HC (Hypothesis 2), the main effect of the grouping variable on the emotion regulation components was significant, with Wilks’s Λ F(4, 179) = 0.64, p < .001, = .37, CI (confidence interval) = [.25, .45]. These results indicate that HC significantly differed from the patient groups in the combined emotion regulation components, but participants with ADHD and participants with BPD did not (see Supplementary Material C for additional information regarding the MANCOVA). Table 2 presents the mean scores of the four emotion regulation components separately for participants with ADHD, participants with BPD, and HC. In both analyses, the multivariate significance test for the interaction between the emotion regulation components and the covariates was nonsignificant, with Wilks’s Λ F(8, 252) = 0.96, p = .69, and Wilks’s Λ F(8, 358) = 0.96, p = .56, respectively. Thus, gender and years of education were no longer considered as covariates in further analyses.

Table 2.

Mean Scores of Emotion Regulation Components for Study Groups.

	ADHD	BPD	HC
	M (SD)	M (SD)	M (SD)
Modifying and Accepting Emotions	1.8 (.76)	1.72 (.92)	2.98 (.70)
Being Aware of Emotions	2.48 (.90)	2.44 (.99)	2.69 (.98)
Making Sense of Emotions	2.26 (.77)	2.09 (.83)	3.13 (.70)
Confronting Emotions With Self-Encouragement	1.91 (.83)	1.83 (.90)	3.22 (.74)

Note. BPD = borderline personality disorder; HC = healthy controls.

The subsequent DA, applied to further investigate and interpret the dimensions that best separated the groups, revealed two discriminant functions, with a combined Wilk’s Λ = .59, χ²(8) = 95.38, p < .001. After removal of the first function, the second function failed statistical significance, with Wilk’s Λ = .99, χ²(3) = 1.18, p = .76. This means that the second function did not significantly contribute to the discrimination of groups. The two functions accounted for 40% (canonical R² = .40) and 8% (canonical R² = .08) of the total relationship between predictors and groups, and for 99.1% and 0.9% of the between-group variability, respectively. Figure 1 shows the discriminant function plot. If there is a large difference between the centroid of one group and the centroid of another along a discriminant function axis, the discriminant function separates the two groups. As derived from Figure 1, the first discriminant function maximally separates patient groups from HC. The structure (loading) matrix displayed in Table 3 contains correlations between predictors and discriminant functions, and helps to interpret the meaning of the discriminant functions. The results in Table 3 indicate that the best predictors for distinguishing patient groups from HC (consistent with the first discriminant function) are “Modifying and Accepting Emotions,” “Making Sense of Emotions,” and “Confronting Emotions With Self-Encouragement” (loadings less than .33 were not interpreted; Tabachnick & Fidell, 2007b).

Figure 1.

Plots of three group centroids on two discriminant functions derived from discriminant analysis on the four emotional regulation components.

Table 3.

Structure (Loading) Matrix Revealed by Discriminant Analysis on the Emotion Regulation Components.

	Discriminant function
	1	2
Modifying and Accepting Emotions	.84	−.16
Being Aware of Emotions	.14	.09
Making Sense of Emotions	.68	.63
Confronting Emotions With Self-Encouragement	.90	−.20

Given the nonsignificant results regarding the separation between ADHD and BPD in MANCOVA and DA, the planned series of ANCOVAs to evaluate the contribution of each emotion regulation component to the separation between ADHD and BPD (Hypothesis 1) was discarded. Four separate ANCOVAs were conducted to evaluate the contribution of each emotion regulation component to the separation of the patient groups (ADHD, BPD) from the HC (Hypothesis 2), while controlling for the remaining emotion regulation components. In each contrast, the mean of the predictor of interest in the HC group was contrasted with the pooled means of the patient groups. The overall ANCOVA only reached statistical significance for “Confronting Emotions With Self-Encouragement” as the dependent variable, at α < .0125, F(2, 180) = 5.29, p = .006. The contrast showed a significant difference between patient groups (ADHD: M = 2.15, SE = 0.07; BPD: M = 2.16, SE = 0.08) and HC (M = 2.52, SE = 0.09), with F(1, 180) = 10.35, p = .002, η² = .05, CI = [.01, .13]. This means that “Confronting Emotions With Self-Encouragement” most clearly distinguished the patient groups from the HC after adjustment for the other emotion regulation components.

Discussion

The objective of the current study was to compare emotion regulation skills across adults with ADHD, adults with BPD, and HC. Emotion regulation was assessed by the 27 items of the ERSQ (Berking & Znoj, 2008), which were consolidated by PCA into four components. These four components reflect emotion regulation processes described in the literature: “Being Aware of Emotions” refers to the ability to draw attention to emotional processes (Gratz & Roemer, 2004), and might be a precondition of successful emotion regulation. “Making Sense of Emotions” reflects the next step of adaptive emotion regulation, whereby the individual gains some distance to the emotional experience by rationally analyzing physiological signs, identifying triggers, and labeling the experience (Heber, Lehr, Riper, & Berking, 2014). “Modifying and Accepting Emotions” incorporates two coping approaches that complement one another: The first approach aims to change aversive emotional states, and includes every attempt of “up- and down-regulation [of] either the magnitude or duration of the emotional response” (Gross, 2013, p. 359). However, endeavors toward changing emotions might not always be possible or adequate, because they can prolong and intensify aversive experiences by evoking secondary emotions, such as anger, shame, or guilt (Choi, Pos, & Magnusson, 2016). Thus, the second approach targets acceptance of ongoing experience, which facilitates emotional processing, distress tolerance, and habituation to intense affects (Wupperman, Fickling, Klemanski, Berking, & Whitman, 2013). “Confronting Emotions With Self-Encouragement” captures the interplay of two distinct processes: First, the ability to face aversive experiences, such as painful emotions, which is the opposite to “experiential avoidance” that has been linked to the development of maladaptive behavior (Chawla & Ostafin, 2007). Experiencing the aversive emotion is required to habituate to the distressing stimulus, and to be able to choose and initiate expedient emotion regulation strategies. And second, the ability to use positive self-instructions to control impulsive behavior, which includes rapid and unplanned behavioral responses without considering the consequences, and is substantially modulated by negative emotions (Sebastian et al., 2014). Overall, the four-component solution of the ERSQ found in the current study represents a meaningful reduction of the rather complex original nine-subscales structure of the measure (Berking & Znoj, 2008), the validity of which is widely supported by the literature.

The main findings of this study were that adults with ADHD or BPD significantly differed from HC in the combined emotion regulation components (Hypothesis 2), but participants with ADHD and participants with BPD did not (Hypothesis 1). The effect size for the difference between the patient group and HC was large (Cohen, 1988), with $η_{p}^{2}$ = .37. Advanced analyses revealed that a combination of three of the four emotion regulation components—“Making Sense of Emotions,” “Modifying and Accepting Emotions,” and “Confronting Emotions With Self-Encouragement”—best separated study participants into a patient group (ADHD, BPD) or HC. However, when each emotion regulation component was tested separately, while considering the other emotion regulation components as covariates, the only significant difference between the patient groups and the HC was for “Confronting Emotions With Self-Encouragement.”

The significant differences in emotion regulation skills between the patient groups (ADHD, BPD) and HC found in this study confirm our second hypothesis, and partially overlap with the results of Berking and Znoj (2008). They reported that patients with affective, somatoform, or anxiety disorders most clearly differed from HC in their ability to understand emotional experiences (Cohen’s d = 0.92), to regulate emotions (d = 0.83), to tolerate aversive emotional states (d = 1.05), and to accept emotions (d = 1.14). They concluded that these aspects of emotion regulation might be especially important for psychological health and well-being, whereas dysregulation in these aspects might crucially contribute to the development of psychopathology. In contrast, our results indicate that what separates patients with ADHD or BPD best from HC is their difficulties in attending emotional experiences without getting into maladaptive impulsive behavior, and that adults with ADHD and BPD cannot be separated by this behavior. “The unwillingness to remain in contact with uncomfortable private events that often manifests in behaviours that serve to avoid unpleasant experiences” resembles the concept of “experiential avoidance” (Sharp, Kalpakci, Mellick, Venta, & Temple, 2015, p. 284). In BPD, higher levels of experiential avoidance have been found to be associated with more borderline features and deliberated self-harm (Chapman, Gratz, & Brown, 2006), and to partially mediate the link between emotion dysregulation and borderline features (Schramm, Venta, & Sharp, 2013). Moreover, experiential avoidance seems to be not only a key contributor to self-injury but also to self-reported impulsiveness (Berghoff, Pomerantz, Pettibone, Segrist, & Bedwell, 2012) and impulsive behavior in general, including substance misuse and binge eating, irrespective of clinical diagnoses (Kingston, Clarke, & Remington, 2010). Although, to the authors’ knowledge, to date no study has examined experiential avoidance in ADHD, there is preliminary evidence indicating that it might contribute to emotion dysregulation in adult ADHD. For example, Knouse and Mitchell (2015) argued that patients with ADHD often engage in overly optimistic thoughts, which function to escape from negative emotions in the short term, but are associated with decreased likelihood of active coping and increased behavioral avoidance in the long term. In addition, mindfulness-based treatments, which have been proposed to reduce experiential avoidance (Chiesa, Anselmi, & Serretti, 2014), are indicated to improve emotion regulation in adults with ADHD (Bachmann, Lam, & Philipsen, 2016; Mitchell, Zylowska, & Kollins, 2015). Mindfulness teaches how to observe emotional states and resist the impulsive urge to act upon them, and is consistent with the concept of emotional impulsivity in ADHD (Barkley & Fischer, 2010) that arises from executive and frontal dysfunction (Sebastian et al., 2014).

The lack of significant differences between adults with ADHD and adults with BPD in emotion regulation skills in this study stands in contrast to our first hypothesis and to recent studies that have reported higher emotion dysregulation in adults with BPD compared with ADHD (Philipsen et al., 2009; Witt et al., 2014). The current findings might differ because of methodological issues. Although recent studies assessed emotion regulation with measures developed to capture BPD or ADHD symptoms, a strategy that is likely to emphasize differences, the current study used a questionnaire, the ERSQ, which was developed especially to assess different aspects of emotion regulation independent of symptoms and diagnosis. Nonetheless, the current findings are supported by a recent study by Prada et al. (2014) who found no differences in the experience and expression of anger, lifetime aggressive behaviors, and substance abuse—all potential indicators of emotion regulation deficits (Axelrod, Perepletchikova, Holtzman, & Sinha, 2011)—between adults with ADHD and adults with BPD. In addition, the current findings support the notion that deficits in emotion regulation are not only a central feature of BPD (Crowell et al., 2009) but also an important domain of psychopathology of ADHD (Bunford et al., 2015; Corbisiero et al., 2013; Graziano & Garcia, 2016; Martel, 2009; Shaw et al., 2014).

The current study has a number of limitations. First, BPD diagnoses were made by experienced clinicians but not confirmed by a structured clinical interview. Second, males were significantly underrepresented in the BPD group, compared with the ADHD group and HC (2:50:30). Despite using gender as a covariate in the analyses, the unequal number of males across groups might have contributed to the nonsignificant association found between emotion regulation and gender in our study. This interpretation is supported by evidence that gender interacts with emotion dysregulation in ADHD (Retz, Stieglitz, Corbisiero, Retz-Junginger, & Roesler, 2012) and BPD (van Zutphen et al., 2015). Third, comorbid diagnoses and deliberate self-harm were not assessed within the study, preventing analyses regarding group differences in substance abuse and self-harming behavior. Substance abuse and self-harm have been conceptualized as behavioral expressions of emotion dysregulation (McKenzie & Gross, 2014), and reported in both adults with ADHD (Allely, 2014; S. S. Lee, Humphreys, Flory, Liu, & Glass, 2011) and BPD (N. K. Lee, Cameron, & Jenner, 2015; Paris, 2005). Fourth, although recent evidence indicates that adults with a combined (inattentive and hyperactive-impulsive) presentation show the highest levels of emotion dysregulation (Reimherr, Marchant, & Olson, 2010), the current study was unable to analyze differences in emotion regulation skills between BPD and different ADHD presentations. Finally, although recent evidence indicates that adults with comorbid BPD and ADHD show particularly high levels of psychopathology and functional impairments (Ferrer et al., 2010; O’Malley et al., 2015; Philipsen et al., 2008; Prada et al., 2014), the current analyses did not include an ADHD plus BPD group, due to the small size of this sample. Future research is needed to explore gender-specific effects of emotion dysregulation in ADHD and BPD, to examine the effects of comorbid disorders on emotion dysregulation in ADHD and BPD, to compare ADHD and BPD in terms of behavioral aspects of emotion dysregulation (e.g., substance misuse, deliberate self-harm), and to examine potential differences in emotional regulation skills between BPD, different ADHD presentations, and comorbid ADHD plus BPD.

In conclusion, as similar deficits in emotion regulation skills were found to be present among both adults with ADHD and BPD, the current findings indicate that the presence of emotion dysregulation alone cannot inform differential diagnosis or clarify comorbidity. Also, both adults with ADHD and BPD might especially profit from psychological interventions targeting the improvement of the ability to attend to aversive emotional experiences without entering into impulsive behavior, such as mindfulness (Mitchell et al., 2017), dialectical behavior therapy (DBT; Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006), or some emotion regulation or skills trainings (Edel, Holter, Wassink, & Juckel, 2014).

Footnotes

Acknowledgements

The authors are grateful to all participants who were willing to take part in the study.

Author Contributions

The study was designed by R.-D.S., S.C., B.M., and P.N. S.C., B.M., M.C., and P.N. contributed to the data collection. M.C. analyzed the data and wrote the first draft. All authors significantly contributed to, and approved the current version of the article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant from the Swiss National Science Foundation (P2BSP1_165354), and by a grant from the Gottfried and Julia Bangerter-Rhyner-Foundation to M.C.

Author Biographies

Marialuisa Cavelti, PhD, is a clinical psychologist at the University Hospital of Psychiatry and Psychotherapy in Bern, Switzerland. Currently, she is a research fellow at Orygen, The National Centre of Excellence in Youth Mental Health in Melbourne, Australia. Her current research interests include emotion regulation difficulties across psychiatric disorders, and the overlap between borderline personality disorder and psychosis.

Salvatore Corbisiero, PhD, is a clinical psychologist at the University of Basel Psychiatric Clinics in Basel, Switzerland. His research interests include emotional dysregulation, diagnostic assessment, psychotherapy, and impairment in adult ADHD and borderline personality disorder.

Hannes Bitto, MSc, is a doctoral student at the Department of Applied Cognitive Psychology, University of Zurich and an assistant at the Department of Clinical Psychology and Psychiatry, University of Basel. His area of research involves applied statistical methods such as scaling of ADHD symptoms and impairments.

Beatrice Moerstedt, PhD, is an assistant at the Department of Clinical Psychology and Psychiatry, University of Basel, Switzerland and a clinical psychologist at the University Hospital of Psychiatry in Basel, Switzerland. Her current research interests include ADHD and related disorders, for example, borderline personality disorder.

Patricia Newark, PhD, has a postdoctoral position in clinical psychology at the University of Basel. She also works as a psychotherapist in her private practice. Her research interests include the study of psychotherapeutic methods, resources, and self-beliefs in adults with ADHD.

Sylvia Faschina, MSc, is a doctoral student and an assistant at the Department of Clinical Psychology and Psychiatry, University of Basel, Switzerland, and a clinical psychologist at the University Hospital of Psychiatry in Basel, Switzerland. Her current research focuses on cognitive and motivational processes on decision making in adults with ADHD.

Andrew Chanen, MBBS, PhD, FRANZCP, is deputy director of research of Orygen, The National Centre of Excellence in Youth Mental Health and head of personality disorder research. He is also a professorial fellow at Centre for Youth Mental Health, the University of Melbourne, and director of clinical services, Orygen Youth Health. His clinical research and knowledge translation interests lie in prevention and early intervention for severe mental disorders, principally personality disorder, along with mood and psychotic disorders.

Franz Moggi, PhD, EMBA, is head psychologist and associate professor at the University of Bern, Switzerland. He is the head of the psychotherapy section, the clinical psychological service, and the addiction research group. His research interests lie in addiction, ADHD, and comorbidity of addiction and other psychiatric disorders.

Rolf-Dieter Stieglitz, PhD, is a professor of clinical psychology and psychiatry at the University of Basel. He is also chief psychologist at the University of Basel Psychiatric Clinics. His research interests include psychodiagnostics and psychotherapy in adult ADHD.

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