Shame as a prospective predictor of self-inflicted injury in borderline personality disorder: A multi-modal analysis

doi:10.1016/j.brat.2009.06.008

Behaviour Research and Therapy

Volume 47, Issue 10, October 2009, Pages 815-822

https://doi.org/10.1016/j.brat.2009.06.008 Get rights and content

Abstract

The primary aim of this study was to examine the prospective association of shame with self-inflicted injury (SII), including suicide attempts and nonsuicidal self-injury, among women with borderline personality disorder (BPD) who were enrolled in a clinical trial (N = 77). A multi-method approach was used to assess self-reported shame, nonverbal shame behaviors, and assessor ratings of shame during an interview regarding antecedents for a recent episode of SII. Higher levels of nonverbal shame behaviors predicted a higher likelihood of subsequent SII, and shorter time to SII, after controlling for past SII as well as other emotions associated with SII. Self-reported state shame and assessor ratings of shame were associated with prospective SII, but not after controlling for other emotions. These findings underscore the important role of shame in SII, particularly shame in the presence of contextual prompts for events that surround episodes of SII.

Section snippets

Participants

Participants were 77 women (M_age = 30.0 years, SD = 7.3) enrolled in a randomized clinical trial of Dialectical Behavior Therapy (DBT; Linehan, 1993) for BPD and self-inflicted injury (SII; i.e., either suicide attempts, NSSI or both).¹ Inclusion criteria were: (a) diagnosis of BPD; (b) female

Descriptive statistics

The majority of the 77 participants were Caucasian (84%; 4% African–American, 2% Asian–American, 10% other), had a high-school education (90%; 22% were college graduates), and earned less than $10,000 per year (72%). Eighty two percent met criteria for current major depressive disorder or dysthymia, 76% met criteria for at least one current anxiety disorder, and 27% met criteria for a current substance use disorder.

See Table 1 for descriptive statistics for self-inflicted injury (SII). In the

Discussion

We hypothesized that individuals with higher levels of shame would have an increased risk of SII, a combination of a higher likelihood of engaging in SII episodes and engaging in SII sooner in the course of psychosocial treatment. Although self-reported shame was associated with an increase risk of SII, this association did not hold up after controlling for fear. This finding could mean that negative self-reported emotions generally, rather than shame specifically, are associated with future

Acknowledgements

This research was supported by the National Institute of Mental Health Grants 5 RO1 MH34486 and K05 MH01593 to Marsha Linehan, and National Research Service Award to Milton Brown.

The authors extend their gratitude to the therapists, clients, and staff at the Behavioral Research and Therapy Clinics (BRTC), without whom this research would not have been possible. We thank Susan Bland, Linda Dimeff, Heidi Heard, Connie Kehrer, Kelly Koerner, Eric Levensky, Deb McGhee, Evelyn Mercier, Shireen

References (69)

A.L. Chapman et al.
Solving the puzzle of deliberate self-harm: the experiential avoidance model
Behaviour Research & Therapy
(2006)
H.B. Kaplan et al.
Self-derogation and suicide: I. Self-derogation as an antecedent of suicidal responses
Social Science & Medicine
(1976)
J. Paris et al.
Long-term follow-up of borderline patients in a general hospital
Comprehensive Psychiatry
(1987)
S.L. Rizvi et al.
The treatment of maladaptive shame in borderline personality disorder: a pilot study of opposite action
Cognitive and Behavioral Practice
(2005)
M.H. Stone et al.
Natural history of borderline patients treated by intensive hospitalization
Psychiatric Clinics of North America
(1987)
M.C. Zanarini et al.
Treatment histories of borderline inpatients
Comprehensive Psychiatry
(2001)
American Psychiatric Association
Diagnostic and statistical manual for mental disorders (DSM-IV)
(1994)
J. Bancroft et al.
The reasons people give for taking overdoses
British Journal of Psychiatry
(1976)
R.F. Baumeister
Suicide as escape from self
Psychological Review
(1990)
A.T. Beck et al.
Clinical and cognitive predictors of suicide

D.S. Bender et al.

Treatment utilization by patients with personality disorders

American Journal of Psychiatry

(2001)

M. Biehl et al.

Matsumoto and Ekman's Japanese and Caucasian Facial Expressions of Emotion (JACFEE): reliability data and cross-national differences

Journal of Nonverbal Behavior

(1997)

J. Birtchnell et al.

The motivation and emotional state of 91 cases of attempted suicide

British Journal of Medical Psychology

(1971)

M. Brown et al.

Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder

Journal of Abnormal Psychology

(2002)

Brown, M.,Rizvi, S. L. (November 2006). Treatment of shame with exposure therapy and opposite action: A multiple...

J.E. Clarkin et al.

Prototypic typology and the borderline personality disorder

Journal of Abnormal Psychology

(1983)

J. Cohen et al.

Applied multiple regression/correlation analysis for the behavioral sciences

(2003)

C.Z. Conklin et al.

Borderline personality disorder in clinical practice

American Journal of Psychiatry

(2005)

M. Crowe

Never good enough – part 1: shame or borderline personality disorder?

Journal of Psychiatric and Mental Health Nursing

(2004)

R.A. Dulit et al.

Clinical correlates of self-mutilation in borderline personality disorder

American Journal of Psychiatry

(1994)

P. Ekman et al.

Unmasking the face

(1975)

P. Ekman et al.

Manual for the facial action coding system

(1978)

P. Ekman et al.

What the face reveals

(1997)

M.B. First et al.

Structured clinical interview for DSM-IV axis I disorders, patient edition (SCID-I/P)

(1995)

M.B. First et al.

Structured clinical interview for DSM-IV personality disorders (SCID-II)

(1997)

A. Frances et al.

Personality and suicide

Annals of the New York Academy of Sciences: Psychobiology of Suicidal Behavior

(1986)

Gilbert

What is shame? Some core issues and controversies

P. Gosselin et al.

Components and recognition of facial expression in the communication of emotion by actors

Journal of Personality and Social Psychology

(1995)

B.F. Grant et al.

Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions

Journal of Clinical Psychiatry

(2008)

J.J. Gross

The emerging field of emotion regulation: an integrative review

Review of General Psychology

(1998)

W.M. Grove et al.

Problems in the classification of personality disorders

Journal of Personality Disorders

(1991)

J. Haines et al.

The psychophysiology of self-mutilation

Journal of Abnormal Psychology

(1995)

D.W. Harder et al.

The assessment of shame and guilt

M.E. Hastings et al.

Shame, guilt, and suicide

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The defective self model of nonsuicidal self-injury (NSSI) theorizes that individuals who are highly self-critical are more likely to choose NSSI to regulate emotions. This model indirectly suggests that individuals who engage in NSSI may experience more self-conscious emotions in response to negative social feedback, increasing risk for near-term NSSI. This study examined (1) whether individuals with a history of NSSI (vs. without) display greater self-conscious and negative emotional reactions to daily social stressors, and more problematic features of these daily social stressors, and (2) whether greater-than-usual negative emotional reactions and social stressor features predict NSSI urges and behaviors in daily life.
Participants were 134 female college students with recent, recurrent NSSI (n = 77) or no NSSI history (n = 57). Participants completed baseline measures of socioemotional functioning and a two-week daily diary protocol.
The NSSI (vs. no NSSI) group reported significantly greater self-conscious and negative emotional reactions to daily social stressors, and social stressors characterized by greater dysfunction. In the NSSI group, experiencing social stressors characterized by greater distress than one's average during the daily diary period was associated with same-day NSSI urges and behavior, greater confusion than one's average predicted same-day NSSI urges, and greater conflict than one's average predicted same-day NSSI behavior. Greater self-conscious and negative emotional reactions to these stressors than one's average predicted same-day NSSI urges and behavior.
Limitations include reliance on self-report, a once-daily assessment, and lack of generalizability to other samples.
Interpersonal conflict and increased self-conscious emotions pose vulnerability for NSSI. Prevention and intervention efforts would benefit from including a focus on interpersonal functioning.
A mixed methods examination of emotional expression and its impact on emotion regulation effectiveness in borderline personality disorder
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Emotional expression (i.e., identifying and labeling emotion using specific words), is theorized to reduce negative emotion and facilitate emotion regulation. However, it remains unclear how individuals with borderline personality disorder express emotion, and whether this influences their emotion regulation. This study examined whether: 1) emotional expression in borderline personality disorder differed from healthy controls based on word valence, emotionality, and vocabulary; and 2) whether such characteristics predict emotion regulation effectiveness across self-reported and physiological emotion domains differentially across these groups.
Individuals with borderline personality disorder (n = 29) and age and sex-matched healthy controls (n = 30) listened to an evocative story, expressed emotion, and regulated emotion by applying Mindfulness or Cognitive Reappraisal. Emotion regulation was measured by changes in self-report, parasympathetic, and sympathetic emotion, while implementing the emotion regulation strategies. The words used to express emotion were coded based on valence, emotionality, and depth of vocabulary.
Generalized estimating equations revealed no differences between groups in valence, emotionality, and vocabulary. Additionally, using a larger emotional vocabulary predicted more effective sympathetic emotion regulation, and using more negatively valenced words predicted more effective parasympathetic emotion regulation across groups.
Among other things, this study is limited by its predominantly female sample, and that it does not determine whether valence, emotionality, or vocabulary independently predict emotional expression effectiveness.
Emotional expression may not be deficient in borderline personality disorder across the indices studied. Using more negative words and broadening vocabulary while expressing emotion may offer emotion regulation benefits.
The relation between measures of explicit shame and borderline personality features in adolescent inpatients
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Shame is a highly negative emotion frequently experienced by individuals with borderline personality disorder (BPD) as well as those with internalizing or externalizing psychopathology. However, few studies have examined whether shame is related to BPD above and beyond other psychopathology. Further, although feelings of shame peak during adolescence, coinciding with the onset of BPD, very few studies have examined the relationship between shame and BPD in adolescence. Therefore, the current study examined (1) whether levels of shame differ between adolescent psychiatric inpatients with and without BPD and (2) whether borderline personality pathology accounts for additional variance in the experience of shame above and beyond internalizing and externalizing psychopathology.
Adolescent psychiatric inpatients (n = 184, 67% female, M age = 15.26) completed clinical interviews and self-report measures as well as self-report measures of three types of explicit shame: state-shame, shame-proneness, and trait-shame.
T-tests revealed that adolescents with BPD reported significantly higher levels of each type of explicit shame. In hierarchical regression models, borderline personality features explained significant additional variance in shame-proneness and trait-shame while controlling for age, gender, and internalizing and externalizing psychopathology.
Our sample was limited by a lack of demographic diversity and healthy control group, and the study did not examine relations with unique internalizing/externalizing disorders or features of BPD.
Our findings contribute to growing evidence that shame is an important component of BPD, particularly during adolescence, and suggest that shame should be addressed in treatment.
Predicting engagement in nonsuicidal self-injury (NSSI) over the course of 12 months: the roles of borderline personality disorder pathology and emotional consequences of NSSI
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Citation Excerpt :
These findings suggest that the more frequent experience of self-conscious emotions following NSSI among individuals with BPD pathology may increase their risk for later NSSI regardless of how often they experience self-conscious emotions before NSSI. When NSSI elicits, exacerbates, or simply fails to decrease negative self-conscious emotions, individuals with BPD pathology may be motivated to engage in NSSI to self-punish, increasing their risk for future NSSI (Brown et al., 2009). In addition to highlighting the relevance of post-NSSI self-conscious emotions in the maintenance of NSSI among individuals with BPD pathology, these findings are consistent with past research indicating that shame was the only negative emotion to increase in frequency after NSSI among individuals with BPD (Kleindienst et al., 2008).
: Despite theories that negative reinforcement in the form of relief from negative emotions maintains nonsuicidal self-injury (NSSI), no studies have examined the extent to which specific emotional consequences of NSSI predict the maintenance of NSSI over time or explain the greater risk for NSSI found among individuals with borderline personality disorder (BPD) pathology. This study examined whether specific emotional consequences of NSSI relate to the continuance of NSSI behavior over a 12-month period and explain the relation of baseline BPD pathology to future NSSI.
: Participants with a history of recent repeated NSSI (N = 84) completed baseline measures of BPD pathology, NSSI, and the emotional antecedents and consequences of NSSI, including self-conscious emotions, undifferentiated negative affect, anger, emptiness, sadness, and anxiety; follow-up data on NSSI were collected every three months for one year.
: Of the emotional consequences of NSSI examined here, only self-conscious emotions significantly predicted the presence and frequency of NSSI during the 12-month follow-up period. Likewise, whereas BPD pathology was not directly associated with later NSSI, both overall BPD pathology and the specific BPD feature of identity problems were indirectly related to the presence of 12-month NSSI through the greater frequency of post-NSSI self-conscious emotions.
: Emotional consequences of NSSI were assessed using a retrospective self-report measure. Only frequency, and not intensity, of emotions before and after NSSI were assessed.
: Results suggest a distinct role of post-NSSI self-conscious emotions in the maintenance of NSSI among individuals with and without BPD pathology.
Associations between humiliation, shame, self-harm and suicidality among adolescents and young adults: A systematic review
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“I Am Ashamed That I Exist. I Feel Like Apologizing for Existing”: The Phenomenology of Shame in Patients With Borderline Personality Disorder: A Qualitative Study
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View all citing articles on Scopus

^☆: This study was first published as the doctoral dissertation of the first author. Brown, M. (2002). The impact of negative emotions on the efficacy of treatment for chronic parasuicide in borderline personality disorder. Doctoral dissertation, University of Washington.

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Shame as a prospective predictor of self-inflicted injury in borderline personality disorder: A multi-modal analysis☆

Abstract

Section snippets

Participants

Descriptive statistics

Discussion

Acknowledgements

Behaviour Research & Therapy

Social Science & Medicine

Comprehensive Psychiatry

Cognitive and Behavioral Practice

Psychiatric Clinics of North America

Comprehensive Psychiatry

Diagnostic and statistical manual for mental disorders (DSM-IV)

The reasons people give for taking overdoses

British Journal of Psychiatry

Suicide as escape from self

Psychological Review

Clinical and cognitive predictors of suicide

Treatment utilization by patients with personality disorders

American Journal of Psychiatry

Matsumoto and Ekman's Japanese and Caucasian Facial Expressions of Emotion (JACFEE): reliability data and cross-national differences

Journal of Nonverbal Behavior

The motivation and emotional state of 91 cases of attempted suicide

British Journal of Medical Psychology

Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder

Journal of Abnormal Psychology

Prototypic typology and the borderline personality disorder

Journal of Abnormal Psychology

Applied multiple regression/correlation analysis for the behavioral sciences

Borderline personality disorder in clinical practice

American Journal of Psychiatry

Never good enough – part 1: shame or borderline personality disorder?

Journal of Psychiatric and Mental Health Nursing

Clinical correlates of self-mutilation in borderline personality disorder

American Journal of Psychiatry

Unmasking the face

Manual for the facial action coding system

What the face reveals

Structured clinical interview for DSM-IV axis I disorders, patient edition (SCID-I/P)

Structured clinical interview for DSM-IV personality disorders (SCID-II)

Personality and suicide

Annals of the New York Academy of Sciences: Psychobiology of Suicidal Behavior

What is shame? Some core issues and controversies

Components and recognition of facial expression in the communication of emotion by actors

Journal of Personality and Social Psychology

Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions

Journal of Clinical Psychiatry

The emerging field of emotion regulation: an integrative review

Review of General Psychology

Problems in the classification of personality disorders

Journal of Personality Disorders

The psychophysiology of self-mutilation

Journal of Abnormal Psychology

The assessment of shame and guilt

Shame, guilt, and suicide