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British Journal of Clinical Psychology (2017), 56, 103–113

© 2016 The British Psychological Society

www.wileyonlinelibrary.com

Interpersonal emotion regulation in Asperger’s syndrome and borderline personality disorder

Bel�en L�opez-P�erez1*, Tamara Ambrona2 and Michaela Gummerum

1

1 School of Psychology, Plymouth University, UK

2 Autonomous University of Madrid, Spain

Objectives. Interpersonal emotion regulation (ER) plays a significant role in how

individuals meet others’ emotional needs and shape social interactions, as it is key to

initiating and maintaining high-quality social relationships. Given that individuals with

borderline personality disorder (BPD) or Asperger’s syndrome (AS) exhibit problems in

social interactions, the aim of this study was to examine their use of different

interpersonal ER strategies compared to normative control participants.

Methods. Thirty individuals with AS, 30 with BPD, and 60 age-, gender-, and education-

matched control participants completed a battery of measures to assess interpersonal ER,

which assessed to what extent participants tended to engage in interpersonal affect

improvement and worsening and to what extent they used different strategies. Before

completing those measures, all groups were screened for disorders of Axis I and Axis II

with the Structured Clinical Interview for DSM-IV Axis I and Axis II Disorders.

Results. Compared to controls, individuals with AS and with BPD engaged less in affect

improvement. No differences were found for affect worsening. Individuals with AS

reported to use less adaptive (attention deployment, cognitive change) and more

maladaptive (expressive suppression) interpersonal ER strategies, compared to individ-

uals with BPD and control participants who did not differ from each other.

Conclusions. The obtained results suggest the need to develop tailored ER interven-

tions for each of the clinical groups studied. Furthermore, they highlight the need to study

further potential differences in intrapersonal and interpersonal ER in clinical populations.

Practitioner points

� Individuals with Asperger’s syndrome (AS) and borderline personality disorder (BPD) engaged significantly less than healthy controls in interpersonal affect improvement.

� Individuals with BPD did not differ from healthy controls in the use of interpersonal strategies. � Individuals with AS reported to use more maladaptive and less adaptive strategies than BPD individuals

and healthy controls.

� Understanding differences in interpersonal emotion regulation in individuals with AS and with BPD and normative controls might help practitioners develop better interventions.

*Correspondence should be addressed to Bel�en L�opez-P�erez, Department of Psychology, Liverpool Hope University, Liverpool L16 9JD, UK (email: [email protected]).

DOI:10.1111/bjc.12124

103

Emotion regulation (ER) consists of different processes aimed at initiating, maintaining, or

changing one’s own (intrapersonal) and others’ (interpersonal) emotions (Gross, 2007).

Typically, research on ER has relied on the process model of emotion regulation (PMER;

Gross, 2007) to study the use of different regulation strategies. The PMER considers that the emotion generation process occurs in a particular sequence, and hence, different ER

strategies can be categorized on the basis of their temporal location along the emotion

generative process. Thus, at the broadest level, regulatory strategies are classified as

antecedent-focused (i.e., strategies that are employed before an emotional response has

become fully activated) or response-focused (i.e., those adopted after an emotional

response has already been generated). Within antecedent-focused, the model makes a

distinction between situation modification, attention deployment, and cognitive change,

whereas response modulation is categorized as response-focused. Although this model was conceived to explain intrapersonal ER, it has also been used to explain interpersonal

ER (Williams, 2007).

Different ER strategies vary in their adaptive value. Intrapersonal ER strategies

intended to down-regulate negative affect, such as rumination (i.e., repetitively focusing

on the experience of negative emotion, its causes and consequences), avoidance (i.e.,

evading negative feelings and thoughts), or expressive suppression (i.e., inhibition of the

expressive emotional response), can lead to increased negative affect (e.g., Aldao, Nolen-

Hoeksema, & Schweizer, 2010) and are positively associated with clinical symptoms (e.g., Webb, Miles, & Sheeran, 2012). Therefore, they have been regarded as maladaptive

strategies, especially if used inflexibly across contexts (e.g., Aldao, Sheppes, & Gross,

2015). However, strategies such as situation modification/problem-solving (i.e., modify-

ing the situation to alter its emotional impact), attention deployment (i.e., diverting

attention), and cognitive change/reappraisal (i.e., reframing a negative event in a positive

way) have been defined as adaptive, as they are effective at reducing negative affect and

are negatively related to clinical symptoms (e.g., Aldao et al., 2010).

Certain clinical populations present deficits in intrapersonal ER (e.g., Barnow et al., 2009). Individuals with borderline personality disorder (BPD) tend to use more

maladaptive strategies such as rumination (e.g., Baer & Sauer, 2011), thought suppression

(e.g., Rosenthal, Cheavens, Lejuez, & Lynch, 2005), and avoidance (e.g., Chapman, Dixon-

Gordon, & Walters, 2011) for down-regulating their own negative emotions. Individuals

with Asperger’s syndrome (AS) tend to use less adaptive intrapersonal ER strategies such

as attention deployment, cognitive change, and situation modification, and more

maladaptive strategies, such as expressive suppression, than controls (Samson, Wells,

Phillips, Hardan, & Gross, 2014). However, no previous research has examined whether those clinical groups encounter difficulties at interpersonal ER.

The term interpersonal ER captures related but still different processes, including

social sharing (i.e., individual’s desire to share their emotional states with others; Rim�e, 2007), the attenuation of one’s own negative affect with the mere presence of others

(Coan, 2011) or modulation of one’s own affect through social interaction (Hofmann,

Carpenter, & Curtiss, 2016), and the different strategies people undertake to change

others’ feelings (Niven, Totterdell, & Holman, 2009). This paper focused on the latter

phenomenon. We believe it is important to study whether individuals with BPD and AS engage in

interpersonal ER, as well as the type of strategies they use for this, as interpersonal ER is a

key process for appropriate interpersonal functioning (Niven et al., 2009). For example,

efforts to engage in affect improvement have been linked in non-clinical samples to a

stronger experience of positive affect for both the agent and the target of the regulatory

104 Bel�en L�opez-P�erez et al.

process (Niven, Totterdell, Holman, & Headley, 2012), as well as a higher probability to

initiate and maintain high-quality relationships (Niven, Holman, & Totterdell, 2012).

Furthermore, the use of behavioural strategies, unlike the use of cognitive ones, has been

linked to higher popularity in non-clinical samples (Niven, Garcia, van der L€owe, Holman, & Mansell, 2015). Conversely, poor interpersonal ER has been linked to lower peer

acceptance (Little, 2001). Thus, given that both individuals with BPD and AS have been

characterized by exhibiting difficulties in interpersonal functioning, studying interper-

sonal ER in these populations can shed some light on the processes underlying their

interpersonal relationships. Beyondexpanding our sparse knowledgeon interpersonal ER

in clinical populations (e.g., Marroqu�ın, 2011), this study can contribute to enhance current psychological interventions focused on emotion dysregulation, such as dialectical

behavioural therapy (DBT) for individuals with BPD (McMain, Korman, & Dimeff, 2001) or cognitive behavioural therapy (CBT) for individuals with AS (Scarpa & Reyes, 2011) by

including the domain of interpersonal ER.

Changing someone else’s mood effectively requires the ability to represent another’s

emotional state, to identify and discriminate between different emotional experiences

(Dunfield, 2014), and to identify the cause of another’s emotional state (e.g., Hoffman,

2000). Individuals with BPD are biased when attributing mental states to others,

evaluating others’ intentions as malevolent (Arntz, 2004; Pretzer, 1990), but they can

accurately infer mental states significantly faster than controls (Frick et al., 2012). Individuals with AS have impairments in both attributing and inferring thoughts, beliefs,

and intentions (e.g., Shamay-Tsoory, Tomer, Berger, Goldsher, & AharonPeretz, 2005).

Furthermore, appropriate interpersonal ER is linked to adequate levels of empathy (Zaki &

Williams, 2013) and both groups have not exhibited such levels. Whereas individuals with

AS are characterized by low levels (e.g., Dziobek et al., 2008), individuals with BPD are

characterized by high levels of empathy (Fertuck et al., 2009). Nevertheless, both low and

high levels of empathy have been linked to maladaptive intrapersonal ER (Schipper &

Petermann, 2013), and therefore, it may be relevant to compare both clinical groups in regard to interpersonal ER. These results, along with the finding that individuals with BPD

and AS experience difficulties in social interactions (e.g., Carrington & Graham, 2001),

suggest that both individuals with BPD and AS may suffer problems in interpersonal ER.

Therefore, we expected that both groups would engage less in interpersonal affect

improvement compared to controls.

We also expected differences between individuals with BPD and AS and controls

concerning the different ER strategies. Situation modification involves being able to

separate emotions and goals and the ability to anticipate possible consequences (Gross, 2007); therefore, we expected individuals with AS to use this strategy less compared to

controls. Given that inferring emotions is intact in individuals with BPD (Arntz, 2004), we

did not expect differences between them and controls. As attention deployment involves

anticipating how a target feels and how it would feel through distraction or concentration

(Gross, 2007), we expected individuals with AS to use this strategy less compared to

individuals with BPD and controls. Cognitive change involves modifying the way the

target thinks about a situation (Gross, 2007), and it involves understanding the causes and

consequences of these emotional responses (Stegge, Terwogt, Reijnjes, & Van Tijen, 2004). Given that this is impaired in individuals with AS (Shamay-Tsoory et al., 2005), we

expected them to use this strategy less compared to individuals with BPD and controls.

Response modulation includes different behaviours targeting physiological responses

that increase or decrease emotion-expressive behaviour (Gross, 2007). Given that both

individuals with BPD and AS have been described as experiencing difficulties with

Emotion regulation in clinical populations 105

controlling their emotional expressions and responses (Kobeleva et al., 2014; Samson,

Huber, & Gross, 2012), we expected both groups to use this strategy more than controls.

Finally, we did not hypothesize correlations between the different scales given that

existing models have not indicated whether a certain strategy may be used more frequently when engaging in affect improvement or worsening. In fact, research from the

domain of intrapersonal ER has suggested that other factors such as the intensity and the

type of emotional response displayed by the target of the regulation process may be a

better predictor of the strategy used (Dixon-Gordon, Aldao, & De Los Reyes, 2015).

Method

Participants

Thirty participants with AS, 30 with BPD, and 60 controls completed the study in

exchange for €7 ($8). Given that participants with AS and BPD differed in gender and

education level, we decided to recruit two control samples. Participants with AS

(Mage = 26.60, SD = 7.32, range 18–43 years; 73% male) did not differ from their control group (CGAS) in age (Mage = 26.70, SD = 7.68, range 18–45 years; t(58) = �0.05, p = .95, d = 0.01), gender, 70% male; v2(1) = 0.08, p = .77, and education level, v2(2) = 0.10, p = .95. Participants with BPD (Mage = 34.07, SD = 8.17, range 18– 43 years; 20% male) did not differ from their control group (CGBPD) in age, Mage = 33.23, SD = 7.80, range 18–45 years; t(58) = 0.40, p = .69, d = 0.11, gender, 24% male; v2(1) = 0.10, p = .75, and education level, v2(2) = 0.13, p = .94 (Table 1).

Procedure

Participants with AS and BPD were recruited from four different mental health institutions in a large city in Spain. All participants with AS had a diagnosis of AS

(ICD10; F84.5), and participants with BPD had a diagnosis of BPD (ICD10; F60.3),

confirmed by a referring psychotherapist or psychiatrist, and were receiving therapy

in their respective institution. A leaflet advertising the study was posted at each

institution and those interested in participating contacted the investigators to arrange

a time for testing. Control participants were recruited from one of the investigator’s

participation pools. Potential control participants were screened so only those who

matched the clinical samples in gender, age, and education were allowed to participate. Two control participants were replaced as they presented with anxiety

disorders and hence did not qualify as healthy controls. All participants signed a

consent form and received general instructions. Then, they were asked to complete

two questionnaires assessing interpersonal ER before being debriefed.

Measures

Psychiatric diagnoses

In all the groups, Axis I and Axis II disorders were assessed using the Spanish version of the

Structured Clinical Interview for DSM-IV Axis I and Axis II Disorders (SCID-I and SCID-II:

First, Spitzer, Williams, & Gibbon, 1999). The SCID-I and SCID-II are a well-validated assessment of Axis I and II disorders, respectively, with very good psychometric

properties (Ks > .70, First, Spitzer, Gibbon, & Williams, 1996). The interviews were administered by two postgraduate psychologists with a substantial concordance on

106 Bel�en L�opez-P�erez et al.

diagnoses between the raters (SCID-I: 0.77 and SCID-II: 0.72). To see current diagnoses for

all groups, please see Table 1.

Emotion regulation of others and self (Niven, Totterdell, Stride, & Holman, 2011; Spanish version by Da

Costa, Paez, Oriol, & Unzueta, 2014)

We only used the scales focused on the assessment of interpersonal ER. Extrinsic affect

improvement is a 6-item scale which evaluates the tendency to deliberately attempt to

improve another person’s feelings (e.g., ‘I listened to someone’s problems to improve

their mood’; a = .80). Extrinsic affect worsening is a 3-item scale which assesses the tendency to deliberately attempt to deteriorate others’ feelings (e.g., ‘I explained to others

how they hurt me or others’; a = .77).

Interpersonal emotion management (Little, Kluemper, Nelson, & Gooty, 2012; Spanish version by Da

Costa et al., 2014)

This 22-item questionnaire assesses, through four different scales, the tendency to use

certain strategies to help others manage their emotions: situation modification (i.e.,

Table 1. Demographics and descriptive statistics for the main study variables by group

Individuals with AS Individuals with BPD CGAS CGBPD

Age 26.60 (7.32) 34.07 (8.17) 26.70 (7.68) 33.23 (7.80)

Gender 73% male 20% male 70% male 24% male

24% female 80% female 30% female 76% female

Education (%)

Basic 27 20 30 17

College 43 40 40 43

University 30 40 40 40

Current Axis I diagnoses (%)

Major depression 6 35 – – Anxiety disorders 5 30 – – Generalized anxiety 8 20 – – Specific phobia 4 0 – – Asperger’s syndrome 100 0 – –

Current Axis II diagnoses (%)

Borderline 0 100 – – Avoidant 0 34 – – Obsessive–Compulsive 7 10 – – Dependant 0 3 – – Paranoid 0 5 – –

Affect improvement 3.23 (0.87) a

3.51 (0.78) a

4.24 (0.36) b

4.09 (0.64) b

Affect worsening 2.96 (0.95) a

3.01 (0.96) b

2.79 (0.92) b

2.58 (0.72) b

Response modulation 4.67 (1.25) a

4.74 (1.45) a

4.89 (1.22) a

4.69 (0.91) a

Attention deployment 3.88 (1.63) a

5.25 (1.21) b

4.88 (1.11) b

5.09 (1.28) b

Cognitive change 4.11 (1.48) a

5.01 (1.42) b

5.32 (0.93) b

4.99 (1.10) b

Suppression 3.59 (1.32) a

2.26 (1.48) b

2.56 (0.92) b

2.49 (1.23) b

Note. BPD = borderline personality disorder; CGAS = control group for individuals with AS; CGBPD = control group for individuals with BPD. Rows with different superscript letters indicate statistically significant differences at p < .05.

Emotion regulation in clinical populations 107

altering a problem to reduce the emotional impact; e.g., ‘I change the situation to alter its

emotional impact’; a = .79), attentional deployment (i.e., directing the target’s attention to something more pleasant; e.g., ‘I distract others’ attention from aspects of the problem

causing undesired emotions’; a = .81), cognitive change (i.e., reappraising a situation as more positive; e.g., ‘When I want others to feel more positive emotions, I put their

problems into perspective’; a = .83), and suppression (i.e., suppressing emotional responses; e.g., ‘I encourage others to keep their emotions for themselves’; a = .82).

Results

Tendency to engage in affect improvement and worsening

Descriptive statistics on the different measures can be found in Table 1. A repeated-

measures analysis of variance (ANOVA) with group (AS, BPD, CGAS, and CGBPD) as

between-subjects factor and type of interpersonal ER (affect improvement, affect

worsening) as within-subjects factor, revealed a significant Group 9 Type interaction,

F(3, 116) = 13.26, p = .001, g2p = .26. A multivariate ANOVA with group (AS, BPD, CGAS, and CGBPD) as independent factor and affect improvement as dependent

variable revealed a significant effect of group, F(3, 119) = 14.30, p = .001, g2p = .27. Pairwise comparisons showed that the two control groups did not differ from each

other (d = 0.14, SE = 0.18, p = .71) and that participants with AS and with BPD did not differ from each other either (d = �0.28, SE = 0.18, p = .55). However, participants with AS and BPD differed from both CGAS (d = �1.01, SE = 0.18, p = .001; d = �0.87, SE = 0.18, p = .001, respectively) and CGBPD (d = �0.73, SE = 0.18, p = .001; d = �0.58, SE = 0.18, p = .01, respectively), as they scored significantly lower in affect improvement. For affect worsening, results of a

multivariate ANOVA did not show a significant effect of group, F(1, 119) = 1.46, p = .23, g2p = .04 (Table 1). At a within group level, individuals with AS did not differ in affect improvement and worsening (d = 0.26, SE = 0.18, p = .14). However, individuals with BPD (d = 0.50, SE = 0.18, p = .01), CGAS (d = 1.45, SE = 0.18, p = .001), and CGBPD (d = 1.52, SE = 0.18, p = .001) reported to engage more in affect improvement than worsening.

Interpersonal ER strategies A repeated-measures ANOVA with group (AS, BPD, CGAS, and CGBPD) as between-subjects

factor and interpersonal ER (IER) strategies (situation modification, attention deployment,

cognitive change, suppression) as within-subjects factor, revealed a significant

Group 9 IER strategies interaction, F(1, 116) = 6.72, p = .001, g2p = .15. Participants from the different groups did not differ in their reported use of situation modification,

F(3, 116) = 0.20, p = .90, g2p = .01. However, there were significant differences between the groups for attention deployment, F(3, 116) = 6.41, p = .001, g2p = .14, cognitive change, F(3, 116) = 4.58, p = .01, g2p = .11, and suppression, F (3, 116) = 6.56, p = .001, g2p = .15. Pairwise comparisons with Bonferroni statistic showed that individuals with AS reported to use attention deployment less compared to

individuals with BPD (d = �1.36, SE = 0.34, p = .001), CGAS (d = �1, SE = 0.34, p = .02), and CGBPD (d = �1.21, SE = 0.34, p = .003). Individuals with AS reported to use cognitive change less compared to individuals with BPD (d = �0.89, SE = 0.32, p = .04), CGAS (d = �1.21, SE = 0.32, p = .002), and CGBPD (d = �0.88, SE = 0.32,

108 Bel�en L�opez-P�erez et al.

p = .04). Individuals with AS reported to use more suppression compared to individuals with BPD (d = 1.33, SE = 0.32, p = .001), CGAS (d = 1.03, SE = 0.32, p = .011), and CGBPD (d = 1.10, SE = 0.32, p = .01).

Discussion

This study investigated whether individuals with BPD and AS differ from each other and

controls in interpersonal ER. Both individuals with BPD and AS reported to engage less in

affect improvement compared to controls. However, no differences were found for affect

worsening. These results suggest that both clinical groups experience difficulties in ER and in social interpersonal functioning (Barnow et al., 2009). Interestingly, individuals

with AS were the only group that did not report to engage more in affect improvement

compared to affect worsening. Thus, individuals with AS tend to engage less in general

interpersonal ER, whereas individuals with BPD tend to engage less in affect improvement

but still significantly more than worsening. These results may be explained by their

difference in theory of mind (ToM). Individuals with AS experience difficulties attributing

and inferring emotions in others (Shamay-Tsoory et al., 2005), which may limit their

efforts to engage in others’ emotions. However, individuals with BPD only encounter difficulties at the attribution level (Arntz, 2004), which may only affect to their efforts to

engage in improving others’ moods.

Regarding specific regulation strategies, individuals with AS reported using less

attention deployment and cognitive change, and more suppression to change others’

feelings. These results further support the idea that due to their deficits in ToM,

individuals with AS not only encounter difficulties when handling their own but also

others’ emotions. Although literature on intrapersonal ER found that individuals with

AS used situation modification less (Samson et al., 2014), in our study we did not find such a difference. This may be explained by the fact that many intervention

programmes for individuals with AS are focused on enhancing social problem-solving

skills, which may be related to situation modification (e.g., Bonete, Calero, &

Fern�andez-Parra, 2015). As hypothesized, individuals with BPD reported to engage less in improving others’

emotions, supporting previous studies that found that individuals with BPD experience

difficulties in social interactions (Whisman & Schonbrun, 2009). Contrary to our

expectations, individuals with BPD reported to use more adaptive (situation modification, attention deployment, and cognitive change) and less maladaptive strategies (suppres-

sion), similar to controls. Individuals with BPD are able to successfully infer emotions in

others (Frick et al., 2012), and thus, they may be more likely to know how to meet others’

emotional needs, unlike individuals with AS. Thus, the difficulties individuals with BPD

experience with intrapersonal ER may not be present at an interpersonal level and this

suggests the need to further study possible differences between intra- and interpersonal

ER.

The present findings may have important implications for current interventions with individuals with AS and BPD. Although emotion dysregulation is a central component of

many intervention programmes for these clinical populations, all of them place a higher

emphasis or only target the intrapersonal domain of ER (e.g., Clarkin, Levy, Lenzenweger,

& Kernberg, 2007; Weinberg et al., 2010). For instance, DBT is a treatment that combines

cognitive behavioural approaches with acceptance-based practices (Linehan, 1993), and

it has been successfully used to treat emotion dysregulation in individuals with BPD

Emotion regulation in clinical populations 109

(McMain et al., 2001). Emotion vulnerability or extreme emotional reactivity to the

environment is a key secondary behaviour addressed in DBT. However, it mainly

considers how individuals with BPD should regulate their own negative affect (e.g., anger)

rather than how they can improve others’ feelings. Hence, when conducting interven- tions, practitioners should consider individuals with BPD’s difficulties to engage in

interpersonal affect improvement by targeting their cognitions about others’ affective

states, as well as behaviours to improve others’ moods. Regarding individuals with AS,

emotion dysregulation has been addressed from CBT focusing exclusively on individuals’

efforts to downregulate their own anxiety (e.g., Chalfant, Rapee, & Carroll, 2007) or anger

(Sofronoff, Attwood, Hinton, & Levin, 2007). A randomized controlled trial with children

with AS by Sofronoff, Eloff, Sheffield, and Attwood (2011) targeted interpersonal ER by

increasing children’s understanding and expression of affection to others. Although this programme is a significant step towards improving interpersonal ER in individuals with

AS, it only targeted one of the possible strategies to change others’ feelings. Given that our

results have shown that individuals with AS tend to engage less in affect improvement and

use more maladaptive strategies, future randomized controlled trials should consider not

only the understanding and expression of affection but also attention deployment or

cognitive reappraisal.

Although the present study adds more information about interpersonal ER in

individuals with BPD and AS, it has some limitations. First, we relied on individuals’ self- reports of interpersonal ER. Future research should consider combining these measures

with observation of people’s interactions or diaries where individuals may register the

target of the interpersonal regulation process, as well as the strategy they used to change

others’ feelings. This approach has been used successfully to study interpersonal

regulation functioning in healthy controls (Parkinson & Simons, 2009; Parkinson, Simons,

& Niven, 2016). Second, we did not include any assessment of ToM to control whether

this variable may account for the obtained results. Hence, future research should evaluate

the role of ToM in interpersonal ER. Finally, future research should also consider evaluating both intrapersonal and interpersonal ER to better understand the similarities

and differences between them in clinical populations in order to further improve current

therapy interventions.

While this study certainly has some limitations, it also has important implications. At a

theoretical level, it expands our knowledge about interpersonal ER in individuals with

BPD and AS, which may help to better understand the factors underlying their difficulties

when interacting with others. At a practical level, the obtained results suggest the need to

develop tailored ER interventions for each of the clinical groups studied. Whereas DBT for individuals with BPD should focus on helping them to engage more in interpersonal affect

improvement, CBT for individuals with AS needs to target the use of more adaptive ER

strategies such as attention deployment and cognitive change. Overall, the obtained

results highlight the need to consider the interpersonal domain of ER when conducting

interventions with these clinical groups as this may enhance their personal well-being and

interpersonal functioning.

Acknowledgements

This study was funded by a Santander Postgraduate Internalization Grant (2014/2015) awarded

to the first author of the manuscript. Furthermore, this research was conducted, while the

position of the first author was funded by ESRC grant ES/K000942/1.

110 Bel�en L�opez-P�erez et al.

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Received 31 May 2016; revised version received 4 November 2016

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