Running head: QUALITY OR QUANTITY

Quality or quantity? A multi-study analysis of emotion regulation skills deficits associated with

Borderline Personality Disorder

Matthew W. Southward & Jennifer S. Cheavens

Department of Psychology, The Ohio State University, Columbus, OH, USA 43210

In press at Personality Disorders: Theory, Research, & Treatment

© 2019, American Psychological Association. This paper is not the copy of record and

may not exactly replicate the final, authoritative version of the article. Please do not copy or cite

without authors' permission. The final article will be available, upon publication, via its DOI:

10.1037/per0000357

Corresponding author:
Matthew W. Southward
181 Psychology Building
1835 Neil Avenue
Columbus, OH 43210
Phone: 614-292-9775
Fax: 614-688-8261
Email: [email protected]

Funding

This work was partially supported by The Ohio State University Center for Clinical and

Translational Science under Grant #TL1TR001069 (to M.W.S.). The funding source had no

involvement in the conduct or preparation of the research.

This work was also partially supported by The Ohio State University Department of Women’s,

Gender and Sexuality Studies under the Coca-Cola Critical Differences for Women Research

Grant (to J.S.C.). The funding source had no involvement in the conduct or preparation of the

research.
Running head: QUALITY OR QUANTITY

Abstract

Linehan’s (1993) biosocial theory posits that people with Borderline Personality Disorder (BPD)

have emotion regulation skills deficits characterized by 1) less frequent use of adaptive emotion

regulation strategies, 2) more frequent use of maladaptive strategies, or 3) poorer quality strategy

implementation (i.e., strategies implemented less skillfully). We tested these possibilities among

participants with BPD, Major Depressive Disorder (MDD), or no disorder (controls). Study 1

participants (N = 272) were recruited online; Study 2 participants (N = 90) completed in-person

diagnostic assessments. The BPD groups reported greater use of maladaptive strategies than the

MDD (d = .35) and control (d = 1.54) groups and lower quality implementation than the MDD (d

= −.33) and control groups (d = −.97). BPD participants reported similar use of adaptive

strategies as the MDD group (d = −.09) but less use than controls (d = −.47). BPD may be

uniquely characterized by overuse of maladaptive strategies and poorer quality emotion

regulation implementation.

Keywords: borderline personality disorder; emotion regulation; skill deficit; major depressive

disorder; skill quality

QUALITY OR QUANTITY 1

Borderline Personality Disorder (BPD) is a severe psychiatric disorder characterized, in

part, by chronic suicidality, affective lability, interpersonal dysfunction, and impulsivity

(American Psychiatric Association [APA], 2013). It is estimated to affect 1.6% of the general

population (Torgersen, 2009) but up to 20% of psychiatric inpatients (Gunderson & Links,

2008). While there may be no gender differences in the rates of BPD in the general population

(Grant et al., 2008), 75% of those presenting with BPD for clinical treatment are female (Widiger

& Trull, 1993). In Linehan’s biosocial theory (Crowell, Beauchaine, & Linehan, 2009; Linehan,

1993), BPD is posited to involve dysregulated emotion regulation functioning (Linehan, 1993, p.

43). For example, people with BPD consistently self-report greater difficulties in emotion

regulation than healthy controls (HCs) and people with anxiety and mood disorders (Fletcher et

al., 2014; Kuo & Linehan, 2009; Neacsiu et al., 2015), Obsessive-Compulsive Personality

Disorder (Steenkamp et al., 2015), and people who engage in non-suicidal self-injury (NSSI)

behaviors (Turner et al., 2015). However, emotion dysregulation has been shown to play a role

in many disorders (Aldao, Nolen-Hoeksema, & Schweizer, 2010), emphasizing the need to

characterize its specific presentations transdiagnostically, as some researchers have begun to do.

Emotion Regulation Skills Deficits

Frequency of skill use.

Emotion regulation strategies are used to influence the onset, duration, and/or type of

emotion experienced (Gross & Thompson, 2007). Emotion regulation strategies are often

classified as generally adaptive (e.g., acceptance, cognitive reappraisal, problem-solving) or

generally maladaptive (e.g., avoidance, rumination, self-harm; Aldao & Nolen-Hoeksema, 2012).

In one study of participants recruited online (Neacsiu & Tkachuck, 2016), those who likely met

criteria for BPD (n = 29) reported using adaptive emotion regulation strategies less frequently
QUALITY OR QUANTITY 2

than those who likely met criteria for another cluster B personality disorder (PD; n = 22; i.e.,

Antisocial PD, Histrionic PD, or Narcissistic PD) and those who likely met criteria for no PD (n

= 77). Conversely, those in the likely BPD group and those in the other PD group reported using

maladaptive strategies more frequently than those in the no PD group.

Daros, Guevara, Uliaszek, McMain and Ruocco (2018) compared participants diagnosed

with BPD (n = 30), a DSM-IV-TR (APA, 2000) mood or anxiety disorder (n = 30), and no

psychiatric disorder (HCs; n = 32). In this study, participants with BPD reported using

maladaptive strategies more frequently than participants in either of the other groups, while those

with BPD reported a similar frequency of adaptive strategy use as those with a mood or anxiety

disorder and a lower frequency of adaptive strategy use than those in the HC group.

In a separate study of participants with BPD (n = 24), MDD (n = 19), or neither

disorder/HCs (n = 32), participants in the BPD group and the MDD group reported using

adaptive emotion regulation strategies less frequently and maladaptive responses more frequently

than those in the HC group (Sauer et al., 2016). There were no significant differences between

participants in the BPD and MDD groups on these measures. Further, when presented with

negatively-valenced images in a laboratory task, there were no differences among the three

groups in the frequency of use of cognitive reappraisal or distraction. The findings from these

three studies suggest those with BPD use adaptive strategies less frequently and maladaptive

strategies more frequently than HCs. People with BPD may use adaptive strategies as frequently

as those with mood or anxiety disorders but less frequently than those with another Cluster B

PD. People with BPD may use maladaptive strategies either more frequently or with similar

frequency as those with a mood or anxiety disorder or a Cluster B PD.

QUALITY OR QUANTITY 3

Quality of skill use.

While it is important to measure the frequency of emotion regulation strategy use,

frequency is at best “a proxy for skillful behavior” (Neacsiu, Rizvi, & Linehan, 2010). One

direct method of measuring skillful behavior is for independent coders to rate the quality of

participants’ emotion regulation skill implementation in response to standardized hypothetical

scenarios without regard to the outcome of the skill use. This approach has several advantages.

First, the use of independent coders reduces the likelihood that differences in the implementation

of skills could be due to participants in different diagnostic groups systematically under- or over-

estimating the quality of their skill use (Morey, 2014; Winter et al., 2015). Second, standardized

hypothetical scenarios enhance internal validity by presenting the same stimulus to all

participants, while potentially enhancing external validity compared to standard laboratory tasks

(e.g., image or video presentation) by describing real-life situations. Finally, rating the quality of

skills without regard to the outcome distinguishes skill quality from skill effectiveness. This is

an important distinction because, while skill effectiveness describes the outcome of emotion

regulation skill use (e.g., reductions in negative affect), skill quality describes the mechanism or

process by which that skill is used. Understanding the process by which participants use skills

allows researchers and clinicians to identify if a skill is being used as intended and, if not, at

what point in the process the breakdown occurs.

One validated measure of emotion regulation skill quality is the Ways of Responding

scale (WOR; Barber & DeRubeis, 1992). This measure presents participants with six

hypothetical stressful scenarios. Examples include being turned down for a job for the third time

in a week, learning that one’s family is disappointed by one’s decision to postpone a visit, and

coming home to a note from a romantic partner saying that they have left the relationship.
QUALITY OR QUANTITY 4

Participants are provided with initial negative thoughts about each scenario (e.g., “Relationships

never turn out well for me. I’m never going to be happy.”) and are asked to write down their

further thoughts in response to the scenario as well as what they would do to handle the scenario.

Independent coders then rate the overall quality of the responses to each scenario based on how

likely the response would be to improve the average person’s mood or circumstances. The WOR

is often used in studies of participants diagnosed with MDD. Across two studies (Adler, Strunk,

& Fazio, 2015; Barber & DeRubeis, 1992), participants with MDD demonstrated medium-to-

large sized differences in WOR scores (ds: −.63 - −1.82) compared to HCs. This preliminary

evidence suggests that the quality of emotion regulation skill implementation, as measured by the

WOR, may differ between healthy controls and those with mood disorders. However, there is no

evidence, to our knowledge, of how the quality of emotion regulation skill implementation

among those with BPD compares to either of these groups.

Current Studies

In the current studies, we aimed to compare both the frequency and quality of

implementation of emotion regulation skills among three groups of participants: those with likely

or diagnosed BPD, those with likely or diagnosed MDD, and healthy control participants (HCs).

We recruited MDD groups to determine if any emotion regulation skills deficits were unique to

BPD or were more indicative of general psychopathology. Based on prior theory and research,

BPD is associated with prolonged experiences of a wider variety of negative emotions (e.g.,

anxiety, anger, shame) than MDD (e.g., primarily sadness) that may lead to more difficulties

engaging in adaptive emotion regulation (Dixon-Gordon, Weiss, Tull, DiLillo, Messman-Moore,

& Gratz, 2015). We hypothesized that participants in the BPD group would report using

adaptive emotion regulation strategies less frequently and demonstrate poorer quality emotion
QUALITY OR QUANTITY 5

regulation implementation than those in the HC or MDD groups. Similarly, we further

hypothesized that participants in the BPD group would report using maladaptive emotion

regulation strategies more frequently than those in the HC or MDD groups.

In line with calls for replication studies in clinical psychology (Tackett et al., 2017), we

conducted two studies. In Study 1, we recruited participants online from Amazon’s Mechanical

Turk (MTurk) website1 to obtain a relatively large sample of mixed gender participants. We

divided participants into three groups based on scores on validated measures of depressive

symptoms and BPD features with established threshold scores. In Study 2, we recruited female

participants to complete in-person structured diagnostic interviews to validate the results from

Study 1 in a clinical sample. Participants in each study completed the same measures of emotion

regulation frequency and quality. Finally, we conducted a mini meta-analysis from both studies

to synthesize the results.

Materials and Methods – Study 1

Participants

An initial sample of 717 participants was recruited in three waves from MTurk between

November and December 2016. Participants were 36.36 years old (SD = 10.94), on average.

The majority of participants identified as female (60.4%) and Caucasian (75.8%). A plurality of

participants reported they were either married (33.8%) or single (29.6%). Similar proportions of

participants reported they had either attained a four-year college degree (34.4%) or attended

some college (31.5%). The median estimated annual income in the current sample was $40,000 -

$49,999. Participants were excluded if they were younger than 18 years old at the beginning of

1
Previous researchers have found that participants recruited via MTurk provide data of similar quality to
that of in-person samples (Necka, Cacioppo, Norman, & Cacioppo, 2016), even when assessing
psychopathology (Shapiro, Chandler, & Mueller, 2013).
QUALITY OR QUANTITY 6

the study; if they could not read English; if they were registered with MTurk as living outside the

United States; or if their MTurk approval rating was less than 95%.

Measures

Demographics. Participants self-reported their age, gender, ethnicity, marital status,

income, education, and history of psychotherapy and psychotropic medication utilization.

DBT Ways of Coping Checklist (DBT-WCCL; Neacsiu, Rizvi, Vitaliano, Lynch, &

Linehan, 2010). The DBT-WCCL is a 59-item self-report scale designed to assess participants’

use of DBT skills (e.g., acceptance, cognitive reappraisal, problem-solving) and maladaptive

coping responses (e.g., avoidance, denial, self-blame). Participants rate how often they used

each coping response in the previous month using a four-point scale, resulting in two subscales: a

DBT Skills Subscale (DSS) and a Dysfunctional Coping Subscale (DCS). In the current sample,

both DSS (α = .95) and DCS (α = .92) items exhibited excellent internal consistency.

Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001). The

PHQ-9 is a 9-item self-report scale designed to assess DSM-IV-TR (APA, 2000) MDD criteria.

Participants use a 0 (not at all) to 3 (nearly every day) scale to rate how often they have

experienced each symptom in the past two weeks, resulting in a total score. In the current

sample, PHQ-9 items exhibited excellent internal consistency (α = .92).

Personality Assessment Inventory – Borderline Subscale (PAI-BOR; Morey, 1991).

The PAI-BOR is a 24-item self-report scale designed to assess features of Borderline Personality

Disorder, including affective instability, identity problems, negative relationships, and NSSI.

Participants use a four-point scale to rate how true each statement is of them, resulting in a total

score. In the current sample, PAI-BOR items exhibited excellent internal consistency (α = .94).
QUALITY OR QUANTITY 7

Ways of Responding Scale (WOR; Barber & DeRubeis, 1992). The WOR is a written

measure of compensatory skills taught in cognitive therapy. Participants read six hypothetical

stressful situations 2 in which initial negative thoughts regarding the event are provided.

Participants then generate responses describing what they would think and do next. Two trained

female undergraduate coders, blind to participant information, independently rated the overall

quality of each response. Quality is defined in the WOR as how likely the response would be to

improve the participant’s mood and circumstances. Higher quality responses typically include

more adaptive strategies and more detail regarding how these strategies would be used. In the

current sample, coders demonstrated excellent agreement regarding overall quality (intraclass

correlation coefficient [ICC] = .93) when averaged across all six responses for each participant.

Study Flow and Procedures

All participants were users of Amazon’s MTurk website and provided informed consent

before beginning the study. This study was approved by the local Institutional Review Board,

and all participants were compensated $4.00 upon study completion.

Participants were recruited in three waves. In Wave 1, participants who did not meet the

exclusion criteria were recruited. These participants completed all measures in a randomized

order. In Wave 2, participants were recruited if they did not meet the exclusion criteria and

scored above Morey’s (1991) threshold score on the PAI-BOR ( 38) suggesting the likely

presence of BPD. Previously, we found that this PAI-BOR threshold score accurately

categorizes those with and without BPD (Southward & Cheavens, 2018). These participants

completed the PAI-BOR first and then completed all remaining measures in a randomized order.

2
These situations include 1) receiving a third job application rejection, 2) being unable to write an essay
for 2 hours, 3) learning that your family is disappointed because you postponed a visit, 4) trying to start a
conversation with a stranger at a party who walks away, 5) coming home to find a note from your spouse
saying they left the relationship, and 6) being turned down for a date by a co-worker.
QUALITY OR QUANTITY 8

In Wave 3, participants were recruited if they did not meet the exclusion criteria, scored below

Morey’s (1991) threshold score on the PAI-BOR (< 38), and met likely criteria for MDD based

on responses to the PHQ-93. These participants completed the PAI-BOR and the PHQ-9 in a

randomized order before completing all other measures in a randomized order.

Although 769 unique responses were originally recorded, 52 of these were removed

because they had a duplicate Internet Service Provider address and/or geographical location

(nremaining = 717). Participants were further deemed ineligible who scored < 38 on the PAI-BOR

in Wave 2 (n = 43; nremaining = 674), who did not meet likely MDD criteria on the PHQ-9 in Wave

3 (n = 165; nremaining = 509), who met likely MDD criteria but scored ≥ 38 on the PAI-BOR in

Wave 3 (n = 126; nremaining = 383), and who provided no data after consenting to the study across

waves (n = 27; nremaining = 356).

Demographic Comparisons

Of the 356 participants deemed eligible for the study, 272 (76.4%) provided complete

data. There were no differences in average age between completers (M = 36.40, SD = 10.61) and

non-completers (M = 36.24, SD = 12.03), t(354) = 0.12, p = .90, 95% CI [–2.86, 2.53], Cohen’s d

= .01; the proportion of women among completers (59.2%) and non-completers (64.3%), χ2(1) =

0.69, p = .40, 95% CI [–7.56, 16.95]; or the proportion of Caucasian participants among

completers (75.7%) and non-completers (76.2%), χ2(1) = 0.01, p = .93, 95% CI [–11.20, 10.70].

We then examined the PAI-BOR and PHQ-9 scores from the completers 4 in each wave to

form three new groups: 1) Healthy Controls (HCs; n = 149), who scored < 38 on the PAI-BOR

and did not meet likely MDD criteria on the PHQ-9; 2) MDD group (n = 54), who scored < 38

3
That is, scoring ≥ 2 on either item #1 or item #2 and scoring ≥ 2 on at least four of items #3-9 (or
scoring ≥ 1 on item #9).
4
We only analyzed data from completers because those who provided partial data only completed 14% of
study questions on average.
QUALITY OR QUANTITY 9

on the PAI-BOR and met likely MDD criteria on the PHQ-9; 3) BPD group (n = 69), who scored

≥ 38 on the PAI-BOR. Of note, 56.5% (n = 39) of the BPD group also met criteria for likely

MDD. There were no significant differences in average age among the HC group (M = 35.83,

SD = 9.85), the MDD group (M = 39.47, SD = 12.79), and the BPD group (M = 35.25, SD =

10.03), F(2, 269) = 2.92, p = .06. There was a smaller proportion of women in the HC group

(49.0%) than in the MDD group (72.2%; χ2(1) = 8.58, p < .01, 95% CI [7.86, 36.07]) and the

BPD group (73.6%; χ2(1) = 11.58, p < .01, 95% CI [10.67, 36.54]), χ2(2) = 15.96, p < .01, but

there were no differences in the proportion of participants who identified as Caucasian in the HC

group (74.5%), the MDD group (83.3%), or the BPD group (72.5%), χ2(2) = 2.22, p = .33.

While there were no significant differences in the proportion of the BPD (5.8%), MDD

(9.3%), and HC (2.0%) groups who had ever participated in DBT, 2(2) = 5.36, p = .07, there

were significant between-group differences in the proportion of participants currently engaged in

talk therapy, 2(2) = 7.79, p = .02. A similar proportion of the BPD (20.3%) and MDD (18.5%)

groups reported current talk therapy, 2(1) = 0.60, p = .81, 95% CI [−12.81, 15.40], while a

larger proportion of both the BPD, 2(1) = 6.69, p = .01, 95% CI [2.69, 23.68], and MDD, 2(1)

= 4.47, p = .03, 95% CI [0.65, 23.24], groups reported current talk therapy than those in the HC

group (8.1%). There was also a significant between-group difference in the proportion of

participants utilizing psychotropic medications, 2(2) = 30.49, p < .01. A similar proportion of

the BPD (33.3%) and MDD (37.0%) groups reported current psychotropic medications, 2(1) =

0.18, p = .67, 95% CI [−12.81, 20.36], while a larger proportion of both the BPD, 2(1) = 22.26,

p < .01, 95% CI [13.88, 37.50], and MDD, 2(1) = 24.95, p < .01, 95% CI [16.14, 42.74], groups

reported current psychotropic medications than those in the HC group (8.1%).

QUALITY OR QUANTITY 10

Analytic Method

We first examined differences in BPD features and depression symptoms among groups.

We checked assumptions of ANOVA by examining the normality of residuals with the Shapiro-

Wilk test; the homogeneity of variances with Levene’s test; and the correlations among the

dependent variables. If these assumptions were satisfied, we conducted one-way ANOVAs5,6;

otherwise, we conducted one-way Kruskal-Wallis H tests using SPSS Version 25 (IBM Corp.,

2017) to compare 1) adaptive emotion regulation strategy frequency, 2) maladaptive emotion

regulation strategy frequency, and 3) quality of emotion regulation implementation among the

HC, MDD, and BPD groups. We followed up these omnibus tests with post hoc t-tests using

Fisher’s least significant differences method. Effect sizes were calculated using Cohen’s

equations (Cohen, 1988) where .20  d  .49 indicates a small effect size, .50  d  .79 indicates

a medium effect size, and d  .80 indicates a large effect size. As an exploratory analysis, we re-

ran ANOVAs with four groups: HC, MDD, BPD, and BPD+MDD.

Results – Study 1

First, we compared PAI-BOR and PHQ-9 total scores among the three groups (Table 1).

There were significant between-group differences in PAI-BOR and PHQ-9 scores. Participants

in the BPD group reported significantly higher PAI-BOR scores than those in the MDD group,

Mdiff = 16.91, SEdiff = 1.57, p < .01, 95% CI [13.81, 20.00], d = 2.56, and those in the HC group,

Mdiff = 29.57, SEdiff = 1.26, p < .01, 95% CI [27.08, 32.05], d = 3.27. Participants in the BPD

group reported similar PHQ-9 scores as those in the MDD group, Mdiff = −1.29, SEdiff = .74, p =

5
Because groups differed significantly in the proportion of women, we also ran univariate ANCOVAs
entering gender as a main effect and as a gender  group product term. Two participants who identified
as transgender were excluded from these analyses because ANCOVAs of a group of two participants
would be underpowered.
6
Because groups nearly differed significantly in average age, we also ran univariate ANCOVAs entering
age as a main effect and as an age  group product term.
QUALITY OR QUANTITY 11

.08, 95% CI [−2.74, .17], d = −.10, but higher PHQ-9 scores than those in the HC group, Mdiff =

11.50, SEdiff = .59, p < .01, 95% CI [10.34, 12.67], d = 1.21. Participants in the MDD group

reported significantly higher PAI-BOR scores, Mdiff = 12.66, SEdiff = 1.38, p < .01, 95% CI [9.95,

15.37], d = 1.36, and PHQ-9 scores, Mdiff = 12.79, SEdiff = .64, p < .01, 95% CI [11.52, 14.06], d

= 3.71, than those in the HC group.

The distribution of three sets of residuals were significantly non-normal: WOR Quality

scores in the HC group, W = .97, df = 149, p < .01; DBT-WCCL-DSS scores in the HC group, W

= .97, df = 149, p < .01; and DBT-WCCL-DCS scores in the BPD group, W = .95, df = 69, p =

.01. All other residuals were normally distributed, Ws > .97, ps > .05. DBT-WCCL-DCS scores

were also significantly heteroscedastic across groups, F(2, 269) = 4.62, p = .01. Because

ANOVA is relatively robust to violations of assumptions (Schmider, Ziegler, Danay, Beyer, &

Bühner, 2010), we only ran both a one-way ANOVA and a Kruskal-Wallis H test for DBT-

WCCL-DCS scores. Because the correlations among DBT-WCCL subscale and WOR Quality

scores were mostly nonsignificant and near zero (Table 2), we did not conduct a MANOVA.

We then tested our main hypotheses (Table 1). There were significant between-group

differences on all three measures of emotion regulation skills: DBT-WCCL-DSS, F(2, 269) =

4.40, p = .01; DBT-WCCL-DCS, F(2, 269) = 70.22, p < .01; and the WOR Quality scale, F(2,

269) = 22.82, p < .017,8. Of note, the Kruskal-Wallis H test for the DBT-WCCLS-DCS was also

significant, H(2) = 99.30, p < .01. We probed each scale with post hoc tests in turn.

On the DBT-WCCL-DSS, the BPD group reported similar frequencies of adaptive

7
When analyzed in univariate ANCOVA models, the group  gender product terms were not significantly
associated with DSS scores, F(2, 263) = .81, p = .44, partial 2 < .01, DCS scores, F(2, 263) = .39, p =
.68, partial 2 < .01, or WOR scores, F(2, 263) = 1.95, p = .14, partial 2 = .02.
8
When analyzed in univariate ANCOVA models, the group  age product terms were not significantly
associated with DSS scores, F(2, 266) = 1.45, p = .24, partial 2 = .01, DCS scores, F(2, 266) = 2.53, p =
.08, partial 2 = .02, or WOR scores, F(2, 266) = 1.76, p = .17, partial 2 = .01.
QUALITY OR QUANTITY 12

strategy use as the MDD group, Mdiff = −.13, SEdiff = .10, p = .20, 95% CI [−.34, .07], d = −.23,

but significantly lower frequency of adaptive strategy use than the HC group, Mdiff = −.24, SEdiff

= .08, p < .01, 95% CI [−.41, −.08], d = −.41. On the DBT-WCCL-DCS, the BPD group

reported a greater frequency of maladaptive strategy use than the MDD, Mdiff = .19, SEdiff = .09,

p = .04, 95% CI [.01, .38], d = .45, and HC groups, Mdiff = .82, SEdiff = .08, p < .01, 95% CI [.67,

.97], d = 1.51. Finally, on the WOR Quality scale, the BPD group provided responses that were

rated as lower quality than the MDD, Mdiff = −.29, SEdiff = .14, p = .04, 95% CI [−.58, −.01], d =

−.37, and HC groups, Mdiff = −.75, SEdiff = .12, p < .01, 95% CI [−.98, −.52], d = −.91.

Exploratory Analyses

When examining HC, MDD, BPD, and BPD+MDD groups, we again found significant

between-group differences on all measures of emotion regulation skills (Table S1, Supplemental

Materials). The BPD+MDD and BPD groups did not significantly differ on any measure of

emotion regulation skill, ps > .05. Only the BPD+MDD group reported significantly greater

frequency of maladaptive skill use than the MDD group, Mdiff = .29, SEdiff = .11, p = .01, 95% CI

[.08, .51], d = .74, and demonstrated lower quality emotion regulation skills than the MDD

group, Mdiff = −.39, SEdiff = .17, p = .02, 95% CI [−.72, −.06], d = −.52.

Discussion – Study 1

In an online sample of participants recruited into three groups (HC, MDD, and BPD), we

found significant group differences in the frequency of adaptive and maladaptive emotion

regulation strategy use and emotion regulation skill quality. Compared to those in the HC group,

participants in the BPD group reported using adaptive strategies less frequently, maladaptive

strategies more frequently, and demonstrated lower quality emotion regulation implementation.

Compared to those in the MDD group, participants in the BPD group reported using adaptive
QUALITY OR QUANTITY 13

strategies just as frequently, maladaptive strategies more frequently, and demonstrated lower

quality emotion regulation implementation. These results suggest that the emotion regulation

skills deficits that may uniquely characterize BPD, relative to MDD, are greater frequency of

maladaptive strategy use and lower quality of emotion regulation implementation, while the

frequency of adaptive strategy use may be more indicative of general psychopathology.

Although the threshold scores used in this study to determine group membership have

been validated in previous clinical samples, these results may be limited in how well they

generalize to a clinical population. To address this concern, we attempted to replicate these

results in a second study in which we recruited participants from the community to complete a

structured diagnostic interview to determine group membership.

Method & Materials – Study 2

Participants

An initial sample of 206 people completed a phone screening assessment to determine

likely study eligibility between November 2016 and December 2017. Of these, 106 were

deemed potentially eligible and completed an in-person structured diagnostic interview at a large

Midwestern university. Of those 106 participants, 90 were determined to be eligible for study

participation. These 90 participants were 32.14 (SD = 12.33) years old on average. All

participants identified as female (100.0%) and the majority of participants identified as

Caucasian (66.7%). A plurality of participants reported they had either some college experience

(41.1%) or had completed a four-year college degree (31.1%), with a median household income

of $40,000 - $49,999. A plurality of participants reported being single/never married (43.3%).

Measures

Demographics. Participants self-reported their age, gender, ethnicity, marital status,

QUALITY OR QUANTITY 14

income, education, and history of psychotherapy and psychotropic medication utilization.

DBT Ways of Coping Checklist (DBT-WCCL; Neacsiu et al., 2010). Details

regarding the DBT-WCCL are provided under Study 1. In Study 2, both DSS (α = .93) and DCS

(α = .92) items exhibited excellent internal consistency.

Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001). Details regarding the

PHQ-9 are provided under Study 1. In Study 2, PHQ-9 items exhibited excellent internal

consistency (α = .91).

Personality Assessment Inventory – Borderline Subscale (PAI-BOR; Morey, 1991).

Details regarding the PAI-BOR are provided under Study 1. In Study 2, PAI-BOR items

exhibited excellent internal consistency (α = .93).

Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I; First,

Spitzer, Miriam, & Williams, 2002). This semi-structured diagnostic assessment is used to

determine the presence or absence of DSM-IV-TR Axis I psychiatric disorders. Previous

researchers have reported fair-to-excellent agreement (s: .61 - .83) on diagnoses assigned using

the SCID-I among a sample of participants in inpatient treatment, outpatient treatment, and

healthy controls (Lobbestael, Leurgans, & Arntz, 2011). In this study, the first author, who

received extensive training over four years by the second author, conducted all SCID-I

assessments.

Structured Clinical Interview for DSM-IV-TR Axis II Disorders (SCID-II; First,

Spitzer, Gibbon, Williams, & Benjamin, 1997). This semi-structured diagnostic assessment is

used to determine the presence or absence of DSM-IV-TR Axis II psychiatric disorders.

Previous researchers have reported excellent agreement (s: .77 - .94) on diagnoses assigned

using the SCID-II among the same sample of participants in inpatient treatment, outpatient
QUALITY OR QUANTITY 15

treatment, and healthy controls (Lobbestael, Leurgans, & Arntz, 2011). The first author also

conducted all SCID-II assessments.

Ways of Responding Scale (WOR; Barber & DeRubeis, 1992). Details regarding the

WOR are provided under Study 1. Two trained female undergraduate coders, blind to participant

information, independently rated the overall quality of each response. In Study 2, coders

demonstrated excellent agreement regarding overall quality (ICC = .94) when averaged across all

six responses for each participant 9.

Study Flow and Procedures

Participants were recruited via referrals from the local university DBT training clinic,

community flyers, and online advertisements. Potential participants completed a phone

screening assessment to determine likely eligibility. Potential participants were excluded if they

met full DSM-IV-TR (APA, 2000) diagnostic criteria for bipolar I disorder, any psychotic

disorder, or a primary substance use disorder. Participants were recruited such that there were no

statistically significant group differences in gender, age, or education level, as these

demographics may be differentially related to patterns of emotion regulation (Gross & John,

2004; Nolen-Hoeksema & Aldao, 2011) or complexity of written responses. Participants who

did not identify as female were excluded because the majority of people with BPD who present

for clinical services are female (Widiger & Trull, 1993). Participants were also excluded if they

were younger than 18 years old at the beginning of the study or if they could not read English.

Potential participants then attended an in-person assessment. Participants first provided

informed consent and then completed the SCID-I and SCID-II. Group assignment was

9
Study 1 raters rated a subset (n = 47) of WOR responses from Study 2 participants. The ICC among all
four raters from both studies, when averaging across all six WOR Overall scores per participant, was .97,
indicating excellent inter-rater agreement.
QUALITY OR QUANTITY 16

determined by diagnostic status. Participants who met no DSM-IV-TR criteria for any current

Axis I or Axis II disorder were assigned to the HC group. Participants who met DSM-IV-TR

criteria for current MDD and who met no more than three criteria for BPD were assigned to the

MDD group. Participants who met DSM-IV-TR criteria for BPD were assigned to the BPD

group. Participants were blind to group assignment. Following the diagnostic assessments,

participants completed all remaining measures online and were thanked, debriefed, and

compensated at a rate of $15 per hour.

Analytic Method

We first compared demographic and diagnostic information among groups. We then

checked assumptions of ANOVA by examining the normality of residuals with the Shapiro-Wilk

test; the homogeneity of variances with Levene’s test; and correlations among dependent

variables. We conducted one-way ANOVAs (and one-way Kruskal-Wallis H tests if ANOVA

assumptions were not met) using SPSS Version 25 (IBM Corp., 2017) to compare 1) adaptive

emotion regulation strategy frequency, 2) maladaptive emotion regulation strategy frequency,

and 3) emotion regulation quality among the HC, MDD, and BPD groups. We followed up

significant omnibus tests with post hoc t-tests using Fisher’s least significant differences method.

As an exploratory analysis, we re-ran ANOVAs with four groups: HC, MDD, BPD, and

BPD+MDD.

Results – Study 2

We first compared demographic and diagnostic information among groups. Groups did

not differ by average age, F(2, 87) = .01, p = .99 or proportion of Caucasian participants, 2(2) =

1.20, p = .55. Groups did differ by the number of DSM-IV-TR diagnoses, F(2, 87) = 92.90, p <

.01. The BPD group (M = 6.03, SD = 2.19) met criteria for significantly more diagnoses than the
QUALITY OR QUANTITY 17

MDD group (M = 3.87, SD = 2.06), Mdiff = 2.17, SEdiff = .45, p < .01, 95% CI [1.28, 3.06], d =

1.02, and HCs (M = 0.00, SD = 0.00), Mdiff = 6.03, SEdiff = .45, p < .01, 95% CI [5.14, 6.92], d =

3.89 (Table 3). More participants in the BPD group had ever participated in DBT (46.7%) than

the MDD group (20%), 2(1) = 4.72, p = .03, 95% CI [2.80, 46.81], or the HC group (0%).

Similar proportions of the BPD (66.7%) and MDD groups (50.0%) reported current psychotropic

medication use, 2(1) = 1.69, p = .19, 95% CI [−7.90, 38.64], and similar proportions of the BPD

(33.3%) and MDD groups (43.3%) reported currently engaging in talk therapy, 2(1) = 0.62, p =

.43, 95% CI [−13.97, 32.45]. More participants in the BPD group (66.7%) reported current

psychotropic medication use than HCs (16.7%), 2(1) = 15.17, p < .01, 95% CI [25.39, 66.91],

while a similar proportion of participants in the BPD group (33.3%) reported current

psychotherapy utilization as HCs (13.3%), 2(1) = 3.30, p = .07, 95% CI [−1.59, 39.60].

As in Study 1, there were significant between-group differences in both PAI-BOR and

PHQ-9 scores (Table 1). The BPD group reported significantly higher PAI-BOR scores than the

MDD group, Mdiff = 13.67, SEdiff = 2.10, p < .01, 95% CI [9.49, 17.84], d = 1.68, and HCs, Mdiff

= 31.23, SEdiff = 2.10, p < .01, 95% CI [27.06, 35.41], d = 3.79. The BPD group reported

significantly lower PHQ-9 scores than the MDD group, Mdiff = −2.97, SEdiff = 1.21, p = .02, 95%

CI [−5.37, −0.57], d = −.58, but significantly higher PHQ-9 scores than HCs, Mdiff = 10.47, SEdiff

= 1.21, p < .01, 95% CI [8.07, 12.87], d = 2.45. The MDD group reported significantly higher

PAI-BOR scores, Mdiff = 17.57, SEdiff = 2.10, p < .01, 95% CI [13.39, 21.74], d = 2.18, and PHQ-

9 scores, Mdiff = 13.43, SEdiff = 1.21, p < .01, 95% CI [11.03, 15.83], d = 2.91, than HCs.

All sets of residuals were relatively normally distributed, Ws > .94, ps > .12. As in Study

1, DBT-WCCL-DCS scores demonstrated significant heteroscedasticity, F(2, 87) = 3.43, p = .02.

We then tested our main hypotheses. There were significant between-group differences
QUALITY OR QUANTITY 18

on all three measures of emotion regulation skills: DBT-WCCL-DSS, F(2, 87) = 6.19, p < .01;

DBT-WCCL-DCS, F(2, 87) = 30.79, p < .01; and the WOR Quality scale, F(2, 87) = 10.55, p <

.01. The Kruskal-Wallis H test for the DBT-WCCLS-DCS was also significant, H(2) = 36.75, p

< .01. We probed each scale with post hoc tests in turn.

On the DBT-WCCL-DSS, the BPD group reported a similar frequency of adaptive

strategy use as the MDD group, Mdiff = .11, SEdiff = .12, p = .37, 95% CI [−.13, .35], d = .22, but

a significantly lower frequency of adaptive strategy use than HCs, Mdiff = −.30, SEdiff = .12, p =

.02, 95% CI [−.55, −.06], d = −.65. On the DBT-WCCL-DCS, the BPD group reported a similar

frequency of maladaptive strategy use as the MDD group, Mdiff = .08, SEdiff = .12, p = .53, 95%

CI [−.17, .32], d = .19, but a significantly greater frequency than HCs, Mdiff = .87, SEdiff = .12, p

< .01, 95% CI [.62, 1.11], d = 1.62. Finally, on the WOR Quality scale, the BPD group

described strategies similar in quality to the MDD group, Mdiff = −.24, SEdiff = .24, p = .24, 95%

CI [−.71, .24], d = −.24, but significantly lower in quality than HCs, Mdiff = −1.04, SEdiff = .24, p

< .01, 95% CI [−1.51, −.57], d = −1.15.

Exploratory Analyses

When examining HC, MDD, BPD, and BPD+MDD groups, we again found significant

between-group differences on all measures of emotion regulation skills (Table S1, Supplemental

Materials). The BPD+MDD and BPD groups did not significantly differ from each other or

from the MDD group on any measure of emotion regulation skill, ps > .15.

Discussion – Study 2

In a sample of participants assigned to three groups (HC, MDD, and BPD) based on

diagnostic status, we found significant group differences in the frequency of adaptive and

maladaptive emotion regulation strategy use and emotion regulation skill quality. Compared to
QUALITY OR QUANTITY 19

those in the HC group, participants in the BPD group reported using adaptive strategies less

frequently, maladaptive strategies more frequently, and demonstrated lower quality emotion

regulation implementation. Compared to those in the MDD group, however, participants in the

BPD group reported using both adaptive and maladaptive strategies just as frequently and

described emotion regulation implementation of similar quality. Unlike the findings in Study 1,

these results suggest that the emotion regulation skills deficits associated with BPD may be more

indicative of general psychopathology than BPD in particular.

A notable strength of Study 2 is the use of validated in-person diagnostic assessments.

However, relying on in-person participation limits the pool of available participants and the

study sample size. Studies with smaller sample sizes typically have less statistical power to

detect smaller effects, which might be expected when comparing the two clinical groups. To

address the limitations and capitalize on the strengths of both Study 1 and Study 2, we conducted

a mini meta-analysis of our results. Finally, to better specify the emotion regulation differences

among groups, we identified the most and least frequently used adaptive and maladaptive

strategies by each group using the full sample.

Methods & Materials – Mini Meta-Analysis

Analytic Method

We first conducted independent samples t-tests to compare PAI-BOR and PHQ-9 scores

between studies. We then entered all information into Goh, Hall, and Rosenthal’s (2016) mini

meta-analysis spreadsheet (version 2). We entered group means and standard deviations for each

study from the DBT-WCCL-DSS, DBT-WCCL-DCS, and the WOR. This allowed us to

calculate Cohen’s d for each comparison involving a BPD group. We then entered these ds and

sample size information from each study to calculate meta-analytic ds, weighted by study sample
QUALITY OR QUANTITY 20

size, as well as standard errors and 95% confidence intervals.

Results – Mini Meta-Analysis

There were no significant between-study differences on PAI-BOR or PHQ-9 scores

among the BPD groups, ps > .09, the MDD groups, ps > .19, or the HC groups, ps > .11. On the

DBT-WCCL-DSS, there were no significant differences between the BPD groups and the MDD

groups, 𝑑̅ = −.09, SE = .15, p = .56, 95% CI [−.38, .21], although the BPD groups reported using

adaptive strategies significantly less frequently than the HC groups, 𝑑̅ = −.47, SE = .13, p < .01,

95% CI [−.72, −.22]. On the DBT-WCCL-DCS, the BPD groups reported using maladaptive

strategies significantly more frequently than the MDD, 𝑑̅ = .35, SE = .15, p = .02, 95% CI [.05,

.64], and HC groups, 𝑑̅ = 1.54, SE = .14, p < .01, 95% CI [1.26, 1.82]. Finally, on the WOR, the

BPD groups described strategies lower in quality than both the MDD, 𝑑̅ = −.33, SE = .15, p =

.03, 95% CI [−.63, −.04], and HC groups, 𝑑̅ = −.97, SE = .13, p < .01, 95% CI [−1.23, −.71].

Specific DBT-WCCL Descriptives

The most frequently used adaptive strategy in both the BPD and MDD groups was

occupying one’s mind with something else (MBPD = 1.94, SDBPD = .91; MMDD = 2.26, SDMDD =

.79); in the HC group, it was focusing on the good things in life (M = 2.29, SD = .84). The least

frequently used adaptive strategy in all groups was surrounding oneself with a nice fragrance to

soothe oneself (MBPD = 1.02, SDBPD = 1.01; MMDD = .70, SDMDD = .89; MHC = .93, SDHC = 1.01).

The most frequently used maladaptive response in the BPD group was self-blame (M =

2.34, SD = .80); in the MDD and HC groups, it was keeping feelings to oneself (MMDD = 2.44,

SDMDD = .70; MHC = 1.67, SDHC = .92). The least frequently used maladaptive response in the

BPD and HC groups was refusing to believe something had happened (MBPD = 1.08, SDBPD =

1.00; MHC = .52, SDHC = .71); in the MDD group, it was finding out who was responsible (M =
QUALITY OR QUANTITY 21

.69, SD = .73).

Exploratory Analyses

When examining HC, MDD, BPD, and BPD+MDD groups, we found significant

differences in the expected direction between each clinical group and HCs (|d|s > .35, ps < .01;

Table S2, Supplemental Materials). Among clinical groups, the only significant differences were

between MDD and BPD+MDD groups, with those in the BPD+MDD group reporting more

frequent use of maladaptive strategies, d = .64, SE = .18, p < .01, 95% CI [.28, 1.00] and lower

quality strategies, d = –.38, SE = .18, p = .03, 95% CI [–.74, –.03] than those in the MDD group.

Discussion

Across two studies, we examined whether BPD was characterized by unique deficits in

emotion regulation strategy use. We found meta-analytic evidence that BPD may be uniquely

characterized by the overuse of maladaptive emotion regulation strategies and lower quality

implementation of emotion regulation strategies, relative to those classified as MDD or HCs.

The frequency with which those in the BPD group used adaptive emotion regulation strategies

was not significantly different from those in the MDD group but was lower than those in the HC

group, indicating a deficit that may be characteristic of psychopathology more generally.

These results provide further empirical support for and help specify Linehan’s (1993)

biosocial theory of BPD. “The thesis [of the biosocial theory] is that borderline individuals

are… deficient in emotion modulation skills. Failures to inhibit maladaptive, mood-dependent

actions are by definition part of the borderline syndrome” (Linehan, 1993, p. 43). These results

provide support for the claim that those with BPD engage more frequently in maladaptive

strategy use than people with mood disorders or no disorder. These results also specify that the

deficiency in emotion modulation skills in BPD may be more accurately characterized as a

QUALITY OR QUANTITY 22

unique deficiency in the quality of implementation of skills (i.e., how well one uses skills) rather

than the frequency with which those skills are used. People with BPD may report a deficit in

adaptive emotion regulation skill frequency relative to HC participants but report a similar

frequency of use relative to those with MDD.

The greater statistical power of these studies also clarifies previous empirical results. In

line with Sauer et al. (2014) and Daros et al. (2018), our results suggest that those with BPD use

adaptive emotion regulation strategies as frequently as those with mood or anxiety disorders. It

is possible that people with BPD only exhibit a unique deficit in the frequency of adaptive

strategy use relative to those with other PDs (Neacsiu & Tkachuck, 2016). Given the relative

dearth of research on personality disorders other than BPD, future researchers are encouraged to

recruit other PD samples to enhance our understanding of baseline emotion regulation deficits

among people with other PDs. Our results also support those of Daros et al. (2018) regarding the

unique deficit characterized by an overuse of maladaptive emotion regulation strategies by those

with BPD relative to those with mood or anxiety disorders. Given the small-to-medium effect

size found in the current studies, it is unsurprising that this difference may not be consistent

across smaller samples (cf. Sauer et al., 2014). Finally, our results extend and complement

previous studies by providing evidence that people with BPD exhibit unique deficits in the

quality of their emotion regulation implementation.

Taken together, these results suggest that people with BPD may be using adaptive

strategies as frequently as those with MDD but doing so less skillfully. In line with

developmental aspects of the biosocial theory, chronic invalidation of those with greater

emotional sensitivity (i.e., those most likely to develop BPD) may impair learning about how to

effectively regulate one’s emotions (Fruzzetti, Shenk, & Hoffman, 2005; Mazursky & Schul,
QUALITY OR QUANTITY 23

2000). The differences in emotion regulation quality and use between those with BPD and MDD

further suggests that those with BPD may be experiencing a wider variety of longer-lasting

negative emotions than people with MDD that may make it more difficult to adaptively tolerate

the accompanying distress. Such difficulties tolerating distress may lead those with BPD to rely

more habitually on strategies that reduce immediate distress, even at the cost of longer-term

goals. In contrast, people with MDD may use fewer maladaptive and higher quality strategies

because they tend to experience a smaller variety of negative emotions (i.e., predominantly

sadness). Future researchers are encouraged to test these hypotheses.

The results of the current studies should be considered in light of their limitations.

Although previously validated in several clinical samples, our measure of adaptive and

maladaptive emotion regulation frequency relied on self-reported responses regarding the

previous month, which may be subject to recall biases (cf. Stone et al., 1998; Todd, Tennen,

Carney, Armeli, & Affleck, 2004). Second, our measure of emotion regulation quality relied on

written responses to hypothetical stressful scenarios. While this method allows for direct

between-subject comparisons, we cannot say how representative these scenarios are of situations

in which participants would regulate their emotions or the degree to which participants’ written

responses reflects their actual emotion regulation behaviors. Thus, it is unclear whether the skills

deficits described here reflect participants’ behaviors or their appraisals of their behaviors.

Further, because coders rated the overall quality of participants’ responses, it is unclear what

specific aspects, if any, of participants’ emotion regulation strategies were of higher or lower

quality. Future researchers may conduct standardized behavioral assessments of participant skill

use to compare both observer and participant ratings of the quality of participants’ emotion

regulation behaviors. Third, because participants in Study 1 completed all study procedures
QUALITY OR QUANTITY 24

online, we cannot verify the veracity of their responses. We attempted to mitigate these concerns

by a) excluding potential participants who completed pre-screening questionnaires multiple times

with different answers and b) including messages emphasizing the need for high quality data

(Zhou & Fishbach, 2016). Fourth, the first author completed all screenings and diagnostic

assessments in Study 2, which may have influenced the reliability and validity of the diagnostic

assessments. Finally, by recruiting participants with MDD as a clinical control group, our

findings do not necessarily generalize beyond mood disorders. In Study 2, participants in the

MDD group met criteria for nearly three comorbid diagnoses on average, suggesting reasonable

variability in diagnostic presentation. Future researchers may recruit participants with disorders

other than MDD or use transdiagnostic criteria to recruit a more varied comparison group.

Despite these limitations, this set of studies embodies principles of reproducible clinical

psychological science advocated for by Tackett et al. (2017). It capitalizes on the strengths of a

larger sample size assessed on dimensional measures (Study 1) along with a verified diagnostic

sample (Study 2). Further, these studies extend previous theoretical work on the biosocial theory

of BPD and empirical work on skills deficits by comparing not only the frequency of adaptive

and maladaptive strategy use but also the quality with which these strategies are used. Our

results provide initial evidence that the quality of emotion regulation implementation among

people with BPD may be as much of a unique deficit as the frequency of maladaptive emotion

regulation use. By specifying these skill deficits, our results offer clear targets for developmental

researchers to understand how such skill deficits arise. These results also offer clinical assessors

more detailed and normative baseline information to consider when evaluating skills deficits

among patients with BPD and MDD as well as validated measures for such assessments.
QUALITY OR QUANTITY 25

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Table 1.
Means, standard deviations, and group comparison statistics of psychopathology, emotion
regulation skill frequency, and emotion regulation quality measures.
HC MDD BPD
Variable M (SD) M (SD) M (SD) F df p
Study 1 (n = 149) (n = 54) (n = 69)
PAI-BOR 16.84 (10.03)a 29.50 (6.89)b 46.41 (6.37)c 278.15 2, 269 < .01
PHQ-9 3.32 (3.60)a 16.11 (2.96)b 14.83 (5.49)b 299.60 2, 269 < .01
DSS 1.66 (0.58)a 1.55 (0.52)a,b 1.42 (0.58)b 4.40 2, 269 .01
DCS 1.07 (0.57)a 1.69 (0.40)b 1.89 (0.48)c 70.22 2, 269 < .01
WOR 3.72 (0.81)a 3.26 (0.67)b 2.97 (0.85)c 22.82 2, 269 < .01
Study 2 (n = 30) (n = 30) (n = 30)
PAI-BOR 14.10 (8.15) a 31.67 (7.94) b 45.33 (8.34)c 110.97 2, 87 < .01
PHQ-9 2.43 (3.68)a 15.87 (5.40)b 12.90 (4.78)c 68.36 2, 87 < .01
DSS 2.09 (0.43)a 1.67 (0.46)b 1.78 (0.52)b 6.19 2, 87 < .01
DCS 1.06 (0.55)a 1.84 (0.32)b 1.92 (0.51)b 30.79 2, 87 < .01
WOR 3.97 (0.82)a 3.16 (0.95)b 2.93 (0.98)b 10.55 2, 87 < .01
Note. HC = Healthy controls. MDD = Major Depressive Disorder. BPD = Borderline
Personality Disorder. PAI-BOR = Personality Assessment Inventory – Borderline subscale.
PHQ-9 = Patient Health Questionnaire – 9. DSS = DBT-WCCL DBT Skills Subscale. DCS =
DBT-WCCL Dysfunctional Coping Subscale. WOR = Ways of Responding scale. Different
subscripts (i.e., a, b, c) indicate statistically significant between-group differences in mean
values of that measure, ps < .05.

Table 2.
Correlations among emotion regulation quality and frequency by group.
HC MDD BPD Full sample
Variable Pair r r r r
Study 1 (n = 149) (n = 54) (n = 69) (n = 272)
DSS-DCS .32** .16 .14 .10
DSS-WOR .23** .12 .06 .22**
DCS-WOR −.04 −.01 −.45** −.33**
Study 2 (n = 30) (n = 30) (n = 30) (n = 90)
DSS-DCS .20 −.28 .36 −.10
DSS-WOR .31 .31 .42* .44**
DCS-WOR −.24 −.14 .08 −.34**
Note. HC = Healthy controls. MDD = Major Depressive Disorder. BPD = Borderline
Personality Disorder. DSS = DBT-WCCL DBT Skills Subscale. DCS = DBT-WCCL
Dysfunctional Coping Subscale. WOR = Ways of Responding scale. * p < .05, ** p
< .01.
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Table 3.
Study 2 sample diagnostics.
HC MDD BPD
(n = 30) (n = 30) (n = 30)
Diagnosis % (n) % (n) % (n) χ2 df p
Bipolar I Disorder 0 (0)a 0 (0)a 0 (0)a – – –
Bipolar II Disorder 0 (0)a 0 (0)a 0 (0)a – – –
Major Depressive Disorder 0 (0)a 100 (30)b 40.0 (12)c 61.07 2 < .01
Dysthymia 0 (0)a 36.7 (11)b 53.3 (16)b 21.27 2 < .01
Psychotic Disorder 0 (0)a 0 (0)a 0 (0)a – – –
Substance Use Disorder 0 (0)a 0 (0)a 6.7 (2)a 4.09 2 .13
Substance Dependence 0 (0)a 3.3 (1)a 13.3 (4)a 5.51 2 .06
Panic Disorder 0 (0)a 10.0 (3)b 36.7 (11)c 16.41 2 < .01
Agoraphobia 0 (0)a 16.7 (5)a,b 23.3 (7)b 7.50 2 .02
Social Anxiety Disorder 0 (0)a 26.7 (8)b 43.3 (13)b 16.03 2 < .01
Specific Phobia 0 (0)a 10.0 (3)a,b 26.7 (8)b 10.59 2 .01
Obsessive-Compulsive Disorder 0 (0)a 10.0 (3)a 13.3 (4)a 4.03 2 .13
Posttraumatic Stress Disorder 0 (0)a 23.3 (7)b 26.7 (8)b 9.12 2 .01
Generalized Anxiety Disorder 0 (0)a 66.7 (20)b 56.7 (17)b 32.04 2 < .01
Anorexia Nervosa 0 (0)a 0 (0)a 0 (0)a – – –
Bulimia Nervosa 0 (0)a 0 (0)a 0 (0)a – – –
Binge Eating Disorder 0 (0)a 10.0 (3)a 0 (0)a 6.21 2 .05
Avoidant PD 0 (0)a 26.7 (8)b 33.3 (10)b 11.67 2 < .01
Dependent PD 0 (0)a 0 (0)a 3.3 (1)a 2.02 2 .36
Obsessive-Compulsive PD 0 (0)a 20.0 (6)b 33.3 (10)b 11.55 2 < .01
Paranoid PD 0 (0)a 10.0 (3)a 46.7 (14)b 23.64 2 < .01
Schizotypal PD 0 (0)a 0 (0)a 10.0 (3)a 6.21 2 .05
Schizoid PD 0 (0)a 6.7 (2)a 0 (0)a 4.09 2 .13
Histrionic PD 0 (0)a 0 (0)a 13.3 (4)a 8.37 2 .02
Narcissistic PD 0 (0)a 0 (0)a 6.7 (2)a 4.09 2 .13
Antisocial PD 0 (0)a 6.7 (2)a 16.7 (5)a 5.89 2 .05
PD - Not Otherwise Specified 0 (0)a 0 (0)a 0 (0)a – – –
Note. HC = Healthy Controls. MDD = Major Depressive Disorder. BPD = Borderline Personality Disorder. PD =
Personality Disorder. Different subscripts indicate statistically significant group differences, ps < .05.
QUALITY OR QUANTITY 34

d = −.41** d = 1.51** d = –.91**

d = −.19 d = −.23 d = 1.19** d = .45* d = –.59** d = –.37*

A. B. C.

Figure 1. A) Study 1 group comparisons of frequency of adaptive strategy use. B) Study 1 group comparisons of frequency of maladaptive
strategy use. C) Study 1 group comparisons of emotion regulation strategy quality. DBT-WCCL = Dialectical Behavior Therapy Ways of
Coping Checklist. WOR = Ways of Responding scale. HC = Healthy Controls. MDD = Major Depressive Disorder. BPD = Borderline
Personality Disorder. Lines represent group means and standard errors. d = Cohen’s d * p < .05 ** p < .01
QUALITY OR QUANTITY 35

d = –.65* d = 1.62** d = –1.15**

d = –.93** d = .22 d = 1.75** d = .19 d = –.91** d = –.24

A. B. C.

Figure 2. A) Study 2 group comparisons of frequency of adaptive strategy use. B) Study 2 group comparisons of frequency of maladaptive
strategy use. C) Study 2 group comparisons of emotion regulation strategy quality. DBT-WCCL = Dialectical Behavior Therapy Ways of
Coping Checklist. WOR = Ways of Responding scale. HC = Healthy Controls. MDD = Major Depressive Disorder. BPD = Borderline
Personality Disorder. Lines represent group means and standard errors. d = Cohen’s d * p < .05 ** p < .01