Graduate School of Psychology
R
ESEARCHM
ASTER’
SP
SYCHOLOGYT
HESISMulti-method assessment of emotional reactivity and return to baseline
in response to abandonment in patients with borderline personality
disorder
Name Hannah van den Eshof
Student number 10000903
Supervisor prof. dr. A. Arntz
Second assessor dr. H.J. Conradi
Abstract
Theories on borderline personality disorder (BPD) hypothesize that the disorder is characterized by emotional dysregulation expressed in heightened emotional reactivity and delayed return to baseline arousal. Previous research on emotional reactivity has shown mixed results, and research on return to baseline is sparse. However, it is suggested that heightened emotional response in BPD might not be general but specific to disorder related schemas as abandonment and rejection. Also, a multi-method assessment of emotional responding is recommended. The current study examines subjective and physiological emotional reactivity and return to baseline in response to abandonment in patients with BPD. Patients with BPD, cluster C-PD and nonpatients viewed film clips (abandonment, concentration camp, neutral, positive) followed by washout periods while subjective emotion and physiological arousal (HRV) was continually collected. BPD patients did not express heightened subjective or physiological emotional reactivity or delayed return to baseline in response to positive, disorder related (abandonment), or disorder nonrelated (concentration camp) stimuli. On the contrary, ClC-PD patients expressed heightened subjective emotional reactivity and delayed return to baseline in response to the disorder nonrelated stimulus (concentration camp). The findings contradict heightened emotional reactivity and delayed return to baseline in BPD. Since the sample size was small and the film clips did not induce physiological arousal, conclusions should be taken with great caution.
Table of contents Abstract 2 Table of Contents 3 List of Tables 4 List of Figures 5 Introduction 6 Methods 9 Operationalization 9 Materials 11 Data analysis 14 Results 15 Baseline 15 Emotional reactivity 16 Return to baseline 22 Discussion 31 References 34
List of Tables
Table 1. A priori contrasts of film clips for 16
analyzing the hypotheses
Table 2. Means and standard deviations for self-reported 38
fear, anger, sadness, arousal and happiness at baseline, start and end of washout by film clip and group
Table 3. Means and standard deviations for self-reported 19
continuous arousal at baseline, peak periods and four time points of washout by film clip and group
Table 4. Means and standard deviations for physiological 22
arousal (HRV) at baseline, peak periods and four time points of washout by film clip and group
Table 5. Means and standard deviations for dissociation by 30
List of Figures
Figure 1. Mean scores of emotion ratings 39
by emotion type, group and film type
Figure 2. Mean scores of self-reported negative emotion 40
by time, group and film type
Figure 3. Mean scores of physiological arousal by time, 41
group and film type
Figure 4. Mean scores of self-reported arousal by time, 42
Introduction
Borderline personality disorder (BPD) is a severe mental disorder characterized by instability in affect, identity and interpersonal relationships (APA, 2000). Up to 84% of BPD patients show suicidal behavior (Soloff et al. 2002), and a reported 10% will eventually die by suicide (Paris & Zweig-Frank, 2001). BPD is primarily a disorder of emotion dysregulation as stated by biosocial theory (Linehan, 1993). Linehan’s theory hypothesizes that the dysregulation of emotions results in patients with borderline personality disorder experiencing 1. heightened sensitivity to
emotional stimuli (low threshold for emotional reactions), 2. heightened emotional reactivity in response to emotional stimuli (intense reactions to emotional stimuli), and 3. delayed return to baseline arousal (long lasting reactions, Linehan, 1993). An important assumption of the theory is that the emotional regulation system itself is disordered, and thus BPD patients may not only experience intense and long lasting reactions in response to negative stimuli but also to positive stimuli. It is important to validate the three aspects (emotional sensitivity, emotional reactivity, return to baseline) of Linehan’s theory (1993), especially since it is the fundament of widely used Dialectical Behaviour Therapy (Linehan, 1993). This study focuses on emotional reactivity and return to baseline in patients with borderline personality disorder.
Emotional reactivity
Previous research on emotional reactivity in BPD showed inconsistent and inconclusive findings. Whereas some studies reported heightened emotional reactivity in BPD (Lobbestael & Arntz 2015; Kuo, Neacsiu, Fitzpatrick, Macdonald, 2014; Rosenthal, Neacsiu, Geiger, Fang, Ahn, Laurauri, 2016; Schmal, Elzinga, Ebner, Simms, Sanislow, Vermetten, et al., 2004; Limberg et al., 2011), others did not (Kuo & Linehan, 2009; Jacob, Hellstern, Ower, Pillmann, Scheel, Rusch, Lieb, 2009; Kuo, Fitzpatrick, Metcalfe, Mcmain, 2016). However, differences in design might explain these mixed results.
First, studies used several types of stimuli to provoke emotions (e.g. films, scripts, sounds, images). Moreover, the content of these stimuli differed from general emotion-eliciting to specific BPD themes. Lobbestael & Arntz (2015) reported heightened emotional responding to the specific stimulus childhood abuse, but not to other negative or positive stimuli. This finding contradicts general heightened emotional reactivity and Lobbestael & Arntz (2015) suggested that BPD patients might only be more reactive to certain borderline-specific stimuli. Limberg, Barnow, Freyberger & Hamm (2011) confirmed this suggestion and found that BPD patients were not more emotionally reactive in general, but showed heightened emotional reactivity when borderline-specific schemas (e.g. rejection and abandonment) were activated.
More research with sufficient variety in valence of emotion-inducing stimuli is needed to draw conclusions about the hypothesized general or disorder specific heightened emotional reactivity in BPD. This study aims contributes to this research area by using both positive and negative, disorder specific and disorder nonspecific stimuli.
Second, the manipulated emotional response has been operationalized differently
between studies. Most research focused on subjective or physiological components of emotional response, and few used a multi-method assessment. However, emotion is defined as a complex array of distinct components including subjective experience, physiological arousal and motoric behavior (Lang, 1979). Consequently, to obtain a thorough understanding of emotional response it is important for studies to include multiple components of emotion. Measuring emotional response with one single component of emotion might even result in a distorted view of full emotional response. For example, subjective emotion was not consistently associated with physiological emotion in the study of Kuo et al. (2014). A possible explanation the authors considered wasthat the different domains of emotion might not be equally sensitive to emotion-inducting stimuli, which resulted in non-corresponding emotional responses. This is in line with Lang’s theory (1979) of emotion stating that the subjective, physiological and motoric
components of emotion are “loosely coupled”, and the different emotional responses might not be synchronous and concordant to one another
.
The above requires research to make use of a multi-method assessment of emotion. Rosenthal et al. (2016) used this multi-method and assessed the multiple components of emotional reactivity (subjective, physiological and motoric) after producing standardized and personal sounds. The study showed that patients with borderline personality disorder reported heightened arousal, and showed heightened physiological arousal to personal negative sounds compared to nonpatients. More research using a multi-method assessment of emotions is required to draw conclusions about the hypothesized heightened emotional reactivity in BPD. This study aims to contribute to this research area by using a multi-method assessment of emotion and another type of emotion-inducing stimuli (film clips).
Return to baseline
Research on return to baseline in patients with borderline personality disorder is sparse. Only three studies looked at this area of research. Two studies using short stories to induce anger (Jacob, Hellstern, Ower, Pillmann, Scheel, Rusch, Lieb, 2009) and shame (Scheel, Schneid, Tescher, Lieb, Tuschen-Caffier, Jacob, 2013) did not find subjective delayed return to baseline in BPD compared to depressed patients and nonpatients. Likewise, Fitzpatrick & Kuo (2015) did
not find delayed physiological or subjective emotional recovery in BPD after provoking anxiety, sadness and anger with short film-clips. Moreover, the same methodological differences as in the ‘reactivity’ line of research apply to ‘return to baseline’ field. Studies differ in type and valence of stimuli, operationalization of emotional response and choice of control groups. This makes it difficult to come to clear conclusions, especially when little research is done. To our knowledge this is the second study focusing on return to baseline using a multi-method assessment of emotions.
In summary, little research is done on emotional return to baseline in patients with borderline personality disorder, and conclusions cannot yet be drawn. On emotional reactivity in patients with borderline personality disorder a considerable amount of research is conducted, however results are mixed and therefore it is difficult to come to clear conclusions. This might be due to methodological differences. 1. Valence of emotional stimuli differed between designs, and there is some evidence that emotional reactivity is specific to BPD related themes. 2. Emotional response is operationalized differently in studies, and it is recommended to use a multi-method approach assessing several components of emotion. Therefore, further research is needed to test Linehan’s theory (1993). This study focuses on emotional reactivity and return to baseline in BPD using a multi-method approach of emotions in response to differently valenced emotion-inducing stimuli. The study was designed with the following features: 1. Emotional response was operationalized as self-reported emotions and arousal, physiological arousal (HRV) and facial expressions. 2. Four film clips with different valences were used to induce emotions; positive, neutral, abandonment and concentration camp. 3. Nonpatient (NpC) and Cluster C personality disorder (ClC-PD) comparison groups were included to be able to draw BPD specific
conclusions. 4. Female-only participants were included in the study to control for sex and because they are overrepresented in the BPD treatment population. Concluding, we hypothesize that BPD patients show heightened (a) self-reported emotion (b) self-reported continuous arousal (c) physiological arousal and (d) motoric expressions in response to (1) positive, (2) negative and (3) disorder related (abandonment) stimuli. Second we hypothesize that BPD patients show delayed return to baseline of (a) self-reported emotion (b) self-reported continuous arousal (c) physiological arousal and (d) motoric expressions in response to the (4) positive, (5) negative and (6) disorder related (abandonment) stimuli.
Method
Operationalization Design
Independent variables
Emotion-inducing stimuli are operationalized by using film-clips. Film-clips are chosen as type of stimulus since they are a proper method of imitating reality, and have shown to be good in inducing emotions (Westermann, Spies, Stahl & Hesse, 1996).
Four film-clips were shown in a semi-random order: abandonment film clip, concentration camp film clip, neutral- and positive clip. The abandonment film clip and concentration camp film clip are programmed not to follow each other, to prevent for carry-over effects of emotions from the one negative film clip to the other.
Dependent variables
Emotional response was operationalized as subjective experience (self-report questionnaires), physiological response (heart rate variability), and motoric behavior (facial expressions).
Emotional reactivity is expressed when compared to baseline heart rate variability is reduced, the intensity and frequency of facial expressions is heightened and the intensity of self-reported emotions and arousal is heightened. Delayed return to baseline is expressed when compared to start of washout, heart rate variability remains reduced, the intensity and frequency of facial expressions remains heightened and the intensity of self-reported emotions and arousal remains heightened at the end of washout.
Comparison groups
Patients with BPD were compared to two control groups, namely patients with cluster-C personality disorders (ClC-PD) and nonpatients controls (NpC).
Procedure
Participants were recruited via online snowballing (nonpatients) and a mental health institution for personality disorders (BPD and ClC-PD). Records of patients who completed the intake procedure at the mental health institution during februari 2017 – april 2017 were screened for in- and exclusion criteria. Eligible patients were invited to participate in the study by the researcher via e-mail and phone. Once people indicated they were willing to participate in the study an appointment was made and the information brochure and informed consent send.
During the appointment the researcher first explained the procedure and answered any questions, after which the information brochure was handed in paper and the informed consent was signed.
Then participants were positioned in a chair facing a computer with video camera and a white background behind them. The researcher explained the physiological device and attached it to the collarbone and upper back of the participant. The participants were told they were going to watch four film clips followed by four washout periods wherein the screen would be black and they could relax and sit still. Participants were asked to continually rate their current emotional arousal on a slide. On top of that at baseline, after each film clip and after each washout participants were asked to rate their current emotions (happy, sad, anger, anxiety, arousal). The following instruction was given for rating their emotions (from Lobbestael & Arntz, 2010; Phillippot, 1993): “We are interested in how the film clips themselves make you feel. Therefore, your ratings
should reflect the emotional impact of the segment on you, rather than your feelings due to other factors, such as the weather or personal problems. People differ in emotionality. We are interested in how these film segments make you feel rather than in how you think you should feel or how you think others would feel.” At the end of the
experiment participants were asked to fill in four dissociation questions per film, and were asked by the researcher what went through their minds during the film clips and washout periods. Lastly, participants were thanked for participation and received a debriefing and small reward (15€).
Sample characteristics In- and exclusion criteria
For the BPD group the main inclusion criteria was a SCID-II diagnosis of borderline personality disorder, for the ClC-PD group a SCID-II diagnosis of cluster c personality disorder and for NpC no diagnosis of psychological disorder.
Participants were excluded from the study when a) male, b) IQ<80, c) severe axis-I disorder (1. bipolar disorder, 2. psychotic disorder, 3. intoxication by alcohol or drugs, 4. addiction requiring detox, 5. acute crisis, 6. immediate suicidal risk), d) no proficiency in Dutch, e) age<18.
Participants in de ClC-PD and NpC conditions were excluded when exceeding a limit of two BPD traits.
Power analysis
A priori power analysis using G*Power (Faul & Erdfelder, 2007) indicated that a total sample of 54 participants was needed to detect medium effects (f=.3) with 96% power using repeated measures within-between interaction ANOVA with alpha at .01.
Materials Diagnosis
The Dutch version of the Structural Clinical Interview for DSM-IV axis II (SCID-II, First, Spitzer, Gibbons, Williams, Benjamin, 1996) was used to assess axis II diagnoses during the intake procedure of the mental health institution for BPD and ClC-PD patients. Nonpatients were screened for axis II diagnoses using SCID-II-screener prior to the experiment. SCID-II has adequate reliability and validity, with good inter-rater reliability (Maffei, Fossati, Agostoni, Barraco, Bagnato, Deborah, Namia, Novella & Petrachi, 1997; Lobbestael, Leurgans & Arntz, 2011).
Film clips
To assess emotional reactivity, all film clips were a priori rated on emotional valence by the researcher and 30s fragments with the highest emotional intensity were selected per film and marked as the peak period. Additionally, the emotional intensity of the 30s peak periods of the film clips was confirmed by average self-reported arousal scores of the complete sample. To assess return to baseline, four time points of 30s (with 60s in between) were selected in the washout periods; 0.00-0.30; 1.30-2.00; 3.00-3.30; 4.30-5.00).
Neutral
For the neutral film clip a 9min during fragment of an underwater movie was shown, with screenings of several fish plants and other sea life. This film clip was targeted to not provoke emotions. The emotionally peak period of this film was selected midway of the film clip.
Abandonment
For the abandonment film clip (BPD related) a fragment of the movie Best Intentions (August Bille, 1992) was chosen. The 12min during film clip depicts a couple in an unhealthy relationship deciding to separate and a child being abandoned by his foster parents. The film clip was
expected to provoke arousal, anxiety, sadness and anger. The emotionally peak period of this film was selected at the moment the child is abandoned.
Concentration camp
For the concentration camp film clip (BPD non-related negative theme) a 10min fragment of the series “Band of Brothers” episode “why we fight” is used, which depicts American soldiers entering a concentration camp. This film clip was chosen because it was expected to provoke arousal, sadness and anger but is not related to BPD themes as rejection, parental abuse and
abandonment. The emotionally peak period of this film was selected at the moment several victims in the camp were shown.
Positive
The positive film clip was a 9min fragment called “Elementary dating” by Mr. Bean. This clip humorously depicts do’s and don’t for men on a first date. This film clip was expected to induce arousal and happiness (Lobbestael & Arntz, 2015; Lobbestael & Arntz, 2010). The emotionally peak period of this film clip was selected at the moment Mr. Bean was in a restaurant on a first date with a girl.
Emotional responding
Heart rate variability
Heart rate variability (HRV) is a measure of the “sympathetic and parasympathetic influences on heart rate that yields information about autonomic flexibility and thereby represents the capacity of regulated emotional responding” (p. 230, Appelhans & Luecken, 2006). Thus, emotional dysregulation is expressed in reduced heart rate variability (Appelhans & Luecken, 2006). HRV was continually assessed during baseline, all film clips and following washout periods.
HRV was measured with a portable heart rate monitor and three ECG stickers attached to the collarbones and upper back. With Vsrrp98 software program the ECG signal was collected, visually inspected and artifacts were hand-corrected if necessary. Root mean square of successive differences in RR intervals (RMSSD) was estimated with Vsrrp98 to assess heart rate variability and average arousal scores were then calculated within 30s time frames.
Emotional reactivity was operationalized as the difference in heart rate variability between baseline and the peak period of each film. Return to baseline was operationalized as the difference in heart rate variability between the time points over the washout periods.
Self-report
After baseline, each film clip and each washout period, participants rated their current state on a 10cm visual analogue scale from “not present” on the one side to “very strong” on the other side. Answers were transformed onto 0-10 scales and included the current state of anger, joy, anxiety, sadness and (retrospective) arousal (see Jacobs et al., 2009).
Participants were also asked to (continually) rate their emotional arousal during the experiment on a slide from “not aroused” on the one side to “very much aroused” on the other side.
Answers were transformed onto 0-10 scales and average scores of arousal were calculated within 30s time frames.
Emotional reactivity was operationalized as the difference in self-reported emotion and arousal between baseline and the peak period of each film. Return to baseline was operationalized as the difference in self-reported emotion and arousal between the time points over the washout periods.
Facial expressions
Facial expressions were gathered through an external video camera attached to the laptop
screening the films. Facial data was analyzed using Facereader (Noldus, 2014), an automatic facial coding software for human facial expressions. Unfortunately, while conducting the research we noted that participants were quite mobile and changed sitting position regularly, turning their heads and leaning on their arms. While analyzing the facial expression data with Facereader (Noldus, 2014) it appeared that is was impossible to extract valid facial expressions from the data and hence they were disregarded from further analysis.
Dissociation
In experiment participants might have coped with their emotions by developing dissociative symptoms, possibly resulting in a null finding of emotional reactivity and return to baseline in BPD. Therefore, to control for dissociation and to gain more insight in the findings 4 items from the Dissociation Tension Scale – Dutch Translation (Stiglmayr et al., 2010) were added to detect dissociative features during the experiment (feeling that one’s surroundings are not real, problems with hearing, feeling that one’s body is not part of oneself and the inability to feel pain). Sum scores of self-reported dissociation were computed for the neutral, positive, concentration camp and abandonment film clips. Cronbach’s alpha was calculated as a measure of the sum scores’ internal consistency and ranged from .97-.99 (high).
Data analysis
To assess possible baseline differences in emotions three one-way between subjects ANOVA’s were conducted with self-reported negative emotion, self-reported arousal and physiological arousal at baseline as dependent variable and group as fixed factor. Paired-sample t-tests were performed to assess whether the neutral, abandonment and concentration camp film clips significantly induced negative emotions compared to baseline.
To test whether self-reported and physiological emotional reactivity differed between groups and films three repeated-measures ANOVA’s were performed with film as a within factor and group as a between factor. Paired-sample t-tests with a priori contrasts (see table 1) were run to compare the effect between films and independent-sample t-tests were performed to compare the effect between groups.
To test whether self-reported and physiological return to baseline differed between groups and films three 3 (films) x 4 (time) repeated-measures ANOVA’s were performed with film and time as within factors and group as a between factor. Paired-sample t-tests with a priori contrasts (see table 1) were run to compare the effect between films and over time and independent-sample t-tests were performed to compare the effect between groups.
Results Baseline
Demographics and baseline differences
In total 305 consecutive intake dossiers from February 1st –April 15th were screened for in- and
exclusion criteria. 39 people were eligible and 266 people were excluded from the study (main reasons 40% male, 12% NAO diagnosis, 10% no treatment at the mental health institution, 9% severe axis-I disorder or acute crisis). From the 39 people who were eligible for participation, 12 people were not interested, 15 people did not reply, and 12 indicated they wanted to participate in the study. From the 12 interested people, five stopped replying or nevertheless decided not to participate in the study, and one person dropped out during the experiment because the film clips disrupted her too much. Eventually data from 11 female participants (4 BPD patients, 2 ClC-PD patients and 5 NpC) between the ages 23-63 was analyzed. The average age of the groups was 37.5 (BPD), 43.0 (ClC-PD) and 33.0 (NpC) years and this difference was not significant (F(2, 10)=.24, p=.79). A one-way between subjects ANOVA was conducted to compare groups on baseline levels of emotional response. Groups did not differ in self-reported negative emotion (F(2, 10)=.26, p=.78), positive emotion (F(2, 10)=.82, p=.47), physiological arousal (F(2, 10)=.68, p=.54), self-reported continuous arousal (F(2, 10)=.10, p=.90) self-reported retrospective arousal (F(2, 10)=.57, p=.59).
Data processing and manipulation check
Sum scores of self-reported negative emotion were computed consisting of items anxiety, anger and sadness for baseline, the neutral, concentration camp and abandonment film clip and their following washouts. Cronbach’s alpha was calculated as a measure of the sum scores’ internal consistency and ranged from .55-.95 (moderate – high). Self-reported positive emotions scores consisted of the item happiness and were computed for baseline, the neutral and positive film clip and their following washout periods. Self-reported retrospective arousal scores consisted of the item arousal and were calculated for baseline, the neutral, concentration camp, abandonment and positive film clip and their following washout periods.
Paired-sample t-tests were conducted to test whether the neutral, abandonment and concentration camp film clips significantly induced negative emotions compared to baseline. As expected the abandonment and concentration camp film clips induced significant reported negative emotion (respectively t(10)=-3.53,p<.01; t(10)=-5.85, p<0.01) and self-reported retrospective arousal (respectively (t(10)=2.53, p=.03; t(10)=4.18, p<.01). Remarkably, the abandonment (t(10)=1.31, p=.22) and concentration camp (t(10)=-.82, p=.43) film clips did not induce significant physiological arousal. Additionally, against expectation the positive film
clip did not significantly induce self-reported positive emotion (t(10)=-.37, p=.72) self-reported retrospective arousal (t(10)=1.03, p=.33) or physiological arousal (t(10)=1.07, p=.31).
Furthermore, as expected the neutral film did not induce significant self-reported negative emotion (t(10)=-.04, p=.97), self-reported retrospective arousal (t(10)=-.22, p=.83) or physiological arousal (t(10)=.31, p=.77) compared to baseline.
Emotional reactivity
a. Self-reported emotions
Data processing and assumptions
Self-reported emotional reactivity was operationalized as the difference between self-reported emotion and self-reported retrospective arousal at baseline and after each film (see table 2 for the mean scores). First, change scores in self-reported negative emotion were calculated between baseline and the neutral, abandonment and concentration camp film clip. Second, change scores in self-reported positive emotion were calculated between baseline and the neutral and positive film clip. Last, change scores in self-reported retrospective arousal were calculated between baseline and all film clips. Shapiro-Wilk’s test of normality indicated that the assumption of normality was not violated for the change scores.
Table 1
A Priori Contrasts of Film clips for Analyzing the Hypotheses Hypotheses Film clips
1abc 2abc 3abc 4abc 5abc 6abc Neutral / positive
Neutral / concentration camp / abandonment Abandonment / concentration camp
Neutral / positive
Neutral / concentration camp / abandonment Abandonment / concentration camp
Hypotheses testing
Mixed repeated-measures ANOVAs were run with film type as within-subject factor and group as between-subjects factor. Mauchly’s test of sphericity indicated that the assumption of
sphericity had not been violated (self-reported negative emotion: χ2(2)=1.14, p=.57; self-reported
Negative emotion
There was a significant main effect of film (F(2, 16)=22.27, p<0.01) on self-reported negative emotion. Paired-sample t-tests with a priori contrasts (see table 1) were run to compare effects between films clips and showed that the concentration camp film clip induced significantly more self-reported emotional reactivity compared to the neutral (t(10)=7.24, p<.01) and abandonment film clips (t(10)=2.74, p=.02). The abandonment film clip induced significantly more
self-reported emotional reactivity compared to the neutral film clip (t(10)=4.54, p<.01). Against expectation, there was no significant main effect of group on self-reported negative emotion (F(2,8)=2.28, p=.17) nor a significant interaction effect of film * group (F(4, 16)=.79, p=.55).
Total dissociation during the experiment was then tested as a covariate but the main effect was not significant (F(1, 7)=.02, p=.89, nor was there an significant interaction effect of film * dissociation (F(2, 14)=.81, p=.46). See table 5 for mean dissociation scores per group.
Positive emotion
Against expectation, there was no significant main effect of film (F(1, 8)=.02, p=.90) or group (F(2, 8)=1.04, p=.40) on self-reported positive emotion. Nor was there an significant interaction effect of film * group (F(2, 8)=.10, p=.91).
Total dissociation during the experiment was then tested as a covariate but the main effect was not significant (F(1, 7)=.75, p=.41), nor was there an significant interaction effect of film * dissociation (F(1, 7)=.29, p=.61).
Retrospective arousal
There was a significant effect of film (F(3, 24)=13.39, p<.01) on self-reported retrospective arousal. Paired-sample t-tests with a priori contrasts (see table 1) were run to compare effects between film clips and showed that the concentration camp film clip induced significantly more self-reported retrospective arousal compared to the neutral (t(10)=5.02, p<.01), positive
(t(10)=3.29, p<.01) and abandonment film clips (t(10)=2.58, p=.03). Second, the abandonment film clip induced significantly more self-reported retrospective arousal compared to the neutral (t(10)=3.65, p<.01) but not to the positive film clip (t(10)=1.04, p=.32). Lastly, the positive film clip induced (trend) significantly more self-reported retrospective arousal compared to the neutral film clip (t(10)=2.10, p=.06). Against expectation, there was no significant main effect of group on self-reported retrospective arousal (F(2, 8)=.30, p=.75) nor an significant interaction effect of film * group (F(6, 24)= 1.64, p=.18).
Total dissociation during the experiment was then tested as a covariate but the main effect was not significant (F(1, 7)=1.88, p=.21). However there was a trend significant interaction effect
of film * dissociation F(1, 7)=4.36, p=.08) on self-reported retrospective arousal. An independent sample t-test was run to compare the effects of dissociation on self-reported retrospective arousal between films and showed that higher levels of dissociation significantly predicted higher levels of retrospective arousal in response to the neutral film clip (t(9)=1.92, p=.04), but not to the concentration camp (t(9)=.54, p=.30), abandonment (t(9)=-.73, p=.24) or positive film clips (t(9)= 1.03, p=.17)
Recap self-reported emotions
Concluding, BPD patients did not express heightened self-reported emotion or retrospective arousal in response to positive (1a) or negative stimuli (2a). Neither did BPD patients express heightened self-reported emotion or retrospective arousal in response to abandonment (3a, see fig. 1). However, higher levels of dissociation predicted higher levels of retrospective reported arousal in response to the neutral film clip.
Table 3
Means and Standard deviations for Self-reported Continuous Arousal at Baseline, Peak periods and four Time points of Washout by Film clip and Group
Film clips Time point Groups
NpC ClC-PD BPD T0 .38 (.85) .35 (.49) .65 (1.25) Neutral T1 T2 T3 T4 T5 1.31 (1.57) .61 (.91) .77 (1.44) .56 (.85) .62 (1.36) .89 (1.25) .86 (.99) 1.51 (.78) 1.91 (.49) 1.96 (.56) 1.66 (1.36) 1.25 (2.33) 1.00 (1.87) .78 (1.40) .68 (1.07) Concentration camp T1 T2 T3 T4 T5 5.22 (1.48) 2.61 (2.27) 1.98 (1.28) 1.69 (1.03) 1.63 (1.10) 8.53 (1.65) 2.92 (4.12) 1.53 (2.15) 1.57 (2.20) 1.79 (2.52) 3.84 (2.83) 2.57 (2.53) 1.42 (1.62) 1.08 (1.79) .76 (1.18) Abandonment Positive T1 T2 T3 T4 T5 T1 T2 T3 T4 T5 3.01 (2.46) 2.10 (2.22) 1.95 (1.27) 1.04 (1.40) .59 (.71) .3.02 (1.74) 1.07 (1.50) 1.04 (1.44) .81 (1.65) .76 (1.65) 6.26 (.60) 1.76 (.42) 1.24 (1.75) .95 (1.34) .46 (.64) 4.79 (2.51) .53 (.75) .37 (.52) 1.03 (1.46) 1.26 (1.77) 4.23 (2.15) 1.67 (2.07) 1.72 (2.22) 1.10 (1.72) .84 (1.11) 3.15 (2.03) 2.03 (2.54) 1.93 (2.24) 1.58 (1.84) .93 (1.38)
Note. Standard deviations are in brackets. T0= baseline, T1= peak period of film clip, T2=washout
(0.00-0.30), T3= washout (1.30-2.00), T4= washout (3.00-3.30), T5= washout (4.30-5.00). b. Self-reported continuous arousal
Data processing and assumptions
Self-reported continuous emotional reactivity was operationalized as the difference between average self-reported continuous arousal at baseline and the peak period of each film (see table 3 for the mean scores). Change scores in self-reported continuous arousal were calculated between baseline and the peak period of each film. Shapiro-Wilk’s test of normality indicated that the assumption of normality was not violated for the change scores.
Hypotheses testing
A mixed repeated-measures ANOVA was run with film type as within-subject factor and group as between-subjects factor. Mauchly’s test of sphericity indicated that the assumption of
sphericity had not been violated χ2(5)=4.00, p=.55.
There was a significant main effect of film on self-reported continuous arousal (F(3, 24)=28.41, p<0.01). A paired-sample t-test with a priori contrasts (see table 1) was run to compare the effect between film clips and showed that the concentration camp film clip induced significantly more self-reported continuous arousal compared to the neutral- (t(10)=5.11 p<.01) and abandonment film clips (t(10)=-2.18, p=.05). The abandonment film clip induced significantly more self-reported continuous arousal compared to the neutral film clip (t(10)=4.19, p<.01) as did the positive film clip (t(10)=5.63, p<.01).
Furthermore, there was no significant main effect of group on self-reported continuous arousal (F(2,8)=.96, p=.43) but there was a significant interaction effect of film * group (F(6, 24)=3.67, p=.01). Independent sample t-tests with a priori contrasts (see table 1) were run to compare effects of the film clips between groups and showed that, against expectation, ClC-PD patients expressed significantly more self-reported continuous arousal in response to the
concentration camp film clip compared to BPD patients (t(4)=2.33, p=.04) and nonpatients (t(5)=-2.30, p=.04). Also ClC-PD patients expressed trend significantly more self-reported continuous arousal in response to the abandonment film clip compared to BPD patients (t(4)=1.59, p=.09) and nonpatients (t(5)=-1.62, p=.08). No differences were found between nonpatients and BPD patients.
Total dissociation during the experiment was then tested as a covariate but the main effect was not significant (F(1, 7)=.50, p=.50), nor was there an significant interaction effect of film * dissociation (F(3, 21)=.1.60, p=.22).
Recap self-reported continuous arousal
Concluding, BPD patients did not express heightened self-reported continuous arousal in response to positive (1b) or negative stimuli (2b). Neither did BPD patients express heightened self-reported continuous arousal in response to abandonment (3b). On the contrary, ClC-patients reported heightened arousal in response to the negative stimuli (concentration camp and
c. Physiological emotional arousal (HRV)
Data processing and assumptions
Physiological emotional reactivity was operationalized as the difference between physiological arousal (HRV) at baseline and each film. Change scores in HRV were calculated between baseline and the peak period of each film (see table 4 for the mean scores). Shapiro-Wilk’s test of
normality indicated that the assumption of normality was violated for the HRV change scores between baseline and the positive film clip in the BPD group (W(4)=.75, p=.03) This was to be expected considering the small sample size. Power transformations did not make the data less skewed and therefore this hypothesis was analysed using non-parametric tests.
Hypotheses testing
A Kruskal Wallis Test was run with film type as within-subject factor and group as between-subjects factor. Against expectation, the groups did not significantly differ in HRV in response to the concentration camp (χ2(2)=.06, p=.97), positive (χ2(2)=.72, p=.68) or abandonment film clip (χ2(2)= 1.45, p=.48). However groups did trend significantly differ in HRV in response to the neutral film clip (χ2(2)=4.66, p=.10). Mann-Whitney U tests were run to compare effects of the neutral film clip between groups and showed that against expectation ClC-PD patients expressed significantly lower HRV (heightened arousal) in response to the neutral film clip compared to BPD patients (Z=-1.85, p=.03) and nonpatients (Z=-1.94, p=.05). No differences were found between BPD patients and nonpatients nor in response to the positive, abandonment or concentration camp film clips.
Recap physiological arousal
Concluding, BPD patients did not express heightened physiological arousal in response to positive (1c) or negative stimuli (2c). Neither did BPD patients express heightened physiological arousal in response to abandonment (3c). On the contrary, ClC-patients expressed heightened physiological arousal in response to the neutral stimulus (see fig. 1).
Table 4
Means and Standard deviations for Physiological Arousal (HRV) at Baseline, Peak periods and four Time points of Washout by Film clip and Group
Film clips Time point Groups
NpC ClC-PD BPD Neutral Concentration Camp Abandonment Positive T0 T1 T2 T3 T4 T5 T1 T2 T3 T4 T5 T1 T2 T3 T4 T5 T1 T2 T3 T4 T5 32.73 (8.25) 40.33 (16.93) 42.11 (9.77) 34.93 (5.64) 41.96 (14.79) 40.01 (13.82) 32.55 (8.14) 48.36 (15.05) 41.04 (21.32) 40.09 (16.11) 32.12 (12.69) 41.74 (13.92) 40.21 (15.16) 42.98 (13.89) 38.10 (13.22) 42.76 (19.26) 39.15 (14.86) 41.73 (11.15) 40.72 (14.18) 41.21 (22.09) 45.50 (18.05) 27.17 (10.93) 10.33 (5.49) 27.91 (7.44) 28.26 (30.20) 16.04 (8.72) 15.76 (8.50) 15.44 (8.96) 23.31 (19.96) 33.24 (37.61) 26.05 (20.70) 29.37 (31.69) 17.36 (10.22) 32.73 (7.07) 15.02 (13.46) 24.33 (24.18) 17.57 (15.54) 20.57 (6.93) 28.12 (31.21) 19.79 (9.86) 16.08 (7.35) 23.13 (23.19) 40.14 (19.06) 42.32 (19.11) 46.14 (23.16) 53.41 (35.60) 40.39 (26.16) 43.18 (21.31) 34.08 (18.87) 55.40 (32.97) 44.45 (25.85) 40.66 (20.77) 35.77 (18.23) 47.90 (26.11) 43.02 (29.71) 42.80 (26.87) 46.85 (29.37) 34.75 (20.20) 56.15 (47.88) 50.94 (32.83) 43.84 (21.63) 47.18 (24.53) 45.36 (44.95)
Note. Standard deviations are in brackets. T0= baseline, T1= peak period of film clip, T2=washout (0.00-0.30),
T3= washout (1.30-2.00), T4= washout (3.00-3.30), T5= washout (4.30-5.00). Return to baseline
a. Self-reported emotions
Data processing and assumptions
Self-reported return to baseline was operationalized as self-reported emotion and retrospective arousal after the washouts of the film clips (see table 2 for the mean scores). Self-reported negative emotion was calculated at the end of washout of the neutral, abandonment and concentration camp film clips. Self-reported positive emotion was calculated at the end of washout of the neutral and positive film clips. Self-reported retrospective arousal was calculated at the end of washout of all film clips. Shapiro-Wilk’s test of normality indicated that the assumption of normality had been violated for the self-reported negative emotion scores at the end of washout of the concentration camp film clip in the BPD (W(4)=.70, p=.01) and
nonpatient (W(5)=.67, p<.01) group. Also the assumption of normality had been violated for the self-reported positive emotion scores at the end of washout of the neutral film clip for
nonpatient group (W(5)=.67, p<.01), the self-reported retrospective arousal scores at the end of washout of the positive film clip for nonpatient group (W(5)=.62, p<.01) and the self-reported retrospective arousal scores at the end washout of the abandonment film clip for BPD group (W(4)=.74, p=.03). This was to be expected considering the small sample size. Power
transformations did not make the data less skewed and with non-parametric tests the hypothesis could not be analysed. Therefore, in the context of the master thesis it was decided to analyse the data as if the assumption of normality had not been violated.
Hypotheses testing
A mixed repeated-measures ANOVA was run with film type and time as within-subject factors and group as between-subjects factor. Mauchly’s test of sphericity indicated that the assumption of sphericity had not been violated for main effects of film (χ2(2)=1.98, p=.37) or significant
interaction effects of film * time (χ2(2)=1.39, p=.50) on self-reported return to baseline of
negative emotion nor for main effects of film (χ2(5)=4.55, p=.48) or significant interaction effects
of film * time (χ2(5)=6.11, p=.30) on self-reported return to baseline of retrospective arousal. Negative emotion
There was a significant main effect of film (F(2, 16)=16.92, p<.01) on self-reported return to baseline of negative emotion. Paired-sample t-tests with a priori contrasts (see table 1) were run to compare the effect between films and showed that the concentration camp film clip still induced significantly more self-reported negative emotion at the end of washout compared to the neutral film clip (t(10)=-2.07, p=.03). The abandonment did not induce significantly more self-reported negative emotion at the end of washout compared to the neutral film clip t(10)=.83, p=.21) or the concentration camp film clip (t(10)=1.09, p=.15).
Furthermore a significant main effect of time (F(1, 8)=15.37,p=.01) on self-reported return to baseline of negative emotion was found. A paired-sample t-test was run to run to analyse the effect of time and showed that self-reported negative emotion was significantly reduced at the end of washout (t(10)=4.54, p<.01). Moreover there was no significant main effect of group (F(2,8)=1.85, p=.22) nor a significant interaction effect of group * film (F(4, 16)=.67, p=.62). But there was a significant interaction effect of time * film (F(2, 16)=13.51, p<.01) Paired-sample t-tests with a priori contrasts (see table 1) were run to compare the effect of the films over time. Self-reported negative emotion was significantly reduced at the end of washout of the
at the end of washout of the neutral film clip (t(10)=-1.71, p=.12). However, against expectation, this did not differ between groups (time * film * group, F(4, 16)=.83, p=.53).
Total dissociation during the experiment was then tested as a covariate but the main effect was not significant (F(1, 7)=1.38, p=.28, nor was there a significant interaction effect of film * dissociation (F(2, 14)=2.65, p=.11), time * dissociation (F(1, 7)=.17, p=.69) or film * time * dissociation (F(2, 14)=.47, p=.64).
Positive emotion
There was no significant main effect of film (F(1, 8)=.09, p=.77) on self-reported return to baseline of positive emotion. Furthermore there was a significant main effect of time (F(1, 8)=10.77,p=.01) on self-reported return to baseline of positive emotion. A paired-sample t-test was run to run to analyse the effect of time and showed that self-reported positive emotion was significantly reduced at the end of washout (t(10)=3.00, p<.01).
Moreover, against expectation, no significant main effect of group (F(2,8)=.15 p=.86) on self-reported return to baseline of positive emotion was found. Neither was there a significant interaction effect of group * film (F(2, 8)=.53, p=.61), time * film (F(1, 8)=.69, p=.43), time * group (F2, 8)=2.48, p=.15) or film * time * group (F(2, 8)=.36, p=.71) on self-reported return to baseline of positive emotion.
Total dissociation during the experiment was then tested as a covariate but the main effect was not significant (F(1, 7)=1.20, p=.31) nor was there a significant interaction effect of film * dissociation (F(1, 7)=.33, p=.58) , time * dissociation (F(1, 7)=.09, p=.77) or film * time * dissociation (F(1, 7)=.11, p=.75).
Retrospective arousal
There was a significant main effect of film (F(3, 24)=12.41, p<.01) on self-reported return to baseline of retrospective arousal. Paired-sample t-tests with a priori contrasts (see table 1) were run to compare the effect between films and showed that the concentration camp film clip did not induce significantly more self-reported retrospective arousal at the end of washout compared to the abandonment (t(10)=.73, p=.24), neutral (t(10)=1.17, p=.14), or positive (t(10)=1.26, p=.12) film clips. Furthermore, the abandonment film clip did not induce significantly more self-reported retrospective arousal at the end of washout compared to the neutral (t(10)=.67, p=.52) or positive (t(10)=.65, p=.27) film clips. Lastly, the positive film clip did not induce significantly more self-reported retrospective arousal at the end of washout compared to the neutral
arousal at start and not at end of washout (as reported in the section self-reported emotional reactivity).
Furthermore, there was a significant main effect of time (F(1, 8)=10.25, p=.01) on self-reported return to baseline of retrospective arousal. A paired-sample t-test was run to analyse the effect of time and showed that self-reported retrospective arousal was significantly reduced at the end of washout (t(10)=3.58, p<.01). Moreover, there was no significant main effect of group (F(2, 8)=0.19, p=.83), nor a significant interaction of group * time (F(2, 8)=2.97, p=.11)
There was a significant effect of group * film (F(6, 24)=3.51, p=.01). Paired-sample t-tests with a priori contrasts (see table 1) were run to compare the effect of the films between groups. ClC-PD patients reported trend significantly more retrospective arousal at the end of washout of the concentration camp film clip (t(4)=1.70, p=.08).but not at the end of washout of the neutral (t(4)=-.83, p=.23), abandonment (t(4)=1.20, p=.30) or positive (t(3.01)=-.87, p=.45) film clips compared to BPD patients. Furthermore, ClC-PD patients reported trend significantly more retrospective arousal at the end washout of the concentration camp film clip (t(5)=1.91, p=.06) but not after washout of the neutral (t(5)=.49, p=.32), abandonment (t(5)=-.38, p=.35) or positive (t(5)=.13, p=.45) film clips compared to NpC. Lastly, no significant differences were found in self-reported retrospective arousal between BPD patients and NpC at the end of washout of the neutral (t(7)=-.37, p=.35), concentration camp (t(7)=-.21, p=42), abandonment (t(7)=1.01, p=.17) or positive (t(7)=-.53, p=.35) film clips.
Moreover, there was a significant interaction effect of film * time (F(3, 24)= 3.17, p=.04). Paired-sample t-tests with a priori contrasts (see table 1) were run to compare the effect between films over time and showed self-reported retrospective arousal was significantly reduced at the end of washout of the concentration camp (t(10)=5.09, p<.01), abandonment (t(10)=2.03, p=.04) and positive (t(10)=1.94, p=.04) film clips but not at the end of washout of the neutral film clip (t(10)=.47, p=.33). However, against expectation, this did not differ between groups (film * time * group, F(6, 24)=.22, p=.97).
Total dissociation during the experiment was then tested as a covariate but the main effect was not significant (F(1, 7)=1.64, p=.24), nor was there a significant interaction effect of film * dissociation (F(3, 21)=.1.78, p=.18) or film * time * dissociation (F(3, 21)=.22, p=.88). But finally, there was a significant interaction effect of time * dissociation (F(1, 7)=6.60, p=.04). An independent sample t-test was run to compare effects of dissociation on self-reported
retrospective arousal over time and showed that higher levels of dissociating trend significantly predicted higher levels of self-reported retrospective arousal at the end of washout (cut-off= 12,
t(9)=1.67, p=.06). This difference was not found in self-reported retrospective arousal at the beginning of washout (t(9)=.83, p=.22)
Recap self-reported emotions
Concluding, BPD patients did not show delayed return to baseline of self-reported emotion or retrospective arousal in response to positive (4a) or negative stimuli (5a). Neither did BPD patients show delayed return to baseline of self-reported emotion or retrospective arousal in response to abandonment (6a). On the contrary, ClC-PD patients reported delayed return to baseline of retrospective arousal in response to negative stimuli (concentration camp film clip, see fig. 2).
b. Self-reported continuous arousal
Data processing and assumptions
Self-reported continuous return to baseline was operationalized as self-reported continuous arousal during the washouts of the film clips (see table 3 for the mean scores). Self-reported continuous arousal was calculated at four time points, time point 1=0.00-0.30; time point 2=1.30-2.00; time point 3=3.00-3.30; time point 4=4.30-5.00) during the washout of the neutral, positive, abandonment and concentration camp film clips. Shapiro-Wilk’s test of normality indicated that the assumption of normality had been violated for the self-reported continuous arousal scores during washout of the neutral (0.00-0.30: W(4)=.68, p<.01; 1.30-2.00: W(4)=.69, p<.01), abandonment (1.30-2.00: W(4)=.74, p=.03), concentration camp (4.30-5.00: W(4)=.68, p<.01) and positive (0.00-0.30: W(4)=.73, p=.03) film clips in the BPD group. Also, the assumption of normality had been violate for the self-reported continuous arousal scores during washout of the abandonment (3.00-3.30: W(5)=.66, p<.01) and positive (1.30-2.00: W(5)=.62, p<.01) film clips in the NpC group. This was to be expected considering the small sample size. Power
transformations make the data less skewed and with non-parametric tests the hypothesis could not be analysed. Therefore in the context of the master thesis it was decided to analyse the data as if the assumption of normality had not been violated.
Hypotheses testing
A mixed repeated-measures ANOVA was run with film type and time as within-subject factors and group as between-subjects factor. Mauchly’s test of sphericity indicated that the assumption of sphericity had not been violated for the main effect of time (χ2(5)=7.46, p=.19) but had been
violated for the main effect of film (χ2(5)=25.09, p<.01). Therefore this effect was reported with
There was no significant main effect of film (F(1.19, 9.56)=3.31, p=.10) or group (F(2, 8)=.07, p=.93). Moreover there was a significant main effect of time (F(3. 24)=3.03, p=.05). A paired sample t-test with a priori contrasts (see table 1) was run to analyse the effects over time and showed that participants reported significantly less arousal at time points 4.30-5.00 compared to 3.00-3.30 t(10)=1.85, p=.05), 3.00-3.30 compared to 1.30-2.00 (t(10)=1.88, p=.04) and 1.30-2.00 compared to 0.00-1.30 (t(10)=2.15, p=.03).
Furthermore, a significant interaction effect of time * film was found (F(9, 72)=3.11, p<.01). Paired-sample t-tests with a priori contrasts (see table 1) were run to compare the effect between films over time and showed that first, participants reported significantly more continuous arousal after the abandonment film clip at time point 0.00-0.30 (t(10)=2.50, p=.02) and 1.30-2.00
(t(10)=1.83, p=.05 but not at time point 3.30-4.00 (t(10)=.56, p=.30) and 4.30-5.00 (t(10)=.94, p=.18) compared to the neutral film clip. Second, participants reported significantly more continuous arousal after the abandonment film clip at time point 0.00-0.30 (t(10)=1.84, p=.05) and 1.30-2.00 (t(10)=1.84, p=.05), but not at time point 3.00-3.30 (t(10)=.33, p=.37) and 4.30-5.00 (t(10)=1.03, p=.16) compared to the positive film clip. Third, participants reported significantly more continuous arousal after the concentration camp film clip at time point 0.00-0.30 (t(10)=2.55, p=.02), 1.30-2.00 (trend, t(10)=1.71, p=.06), 3.30-3.30 (t(10)=2.04, p=.04), and 4.30-5.00 (trend, t(10)=1.52, p=.08) compared to the neutral film clip. Fourth, participants reported significantly more continuous arousal after the concentration camp film clip at time point 0.00-0.30 (t(10)=2.85, p=.01) and 4.30-5.00 (trend, t(10)=1.59, p=.07) but not at time point 1.30-2.00 (t(10)=1.29, p=.11) and 3.00-3.30 (t(10)=.96, p=.18) Fifth, participants reported
significantly more continuous arousal after the concentration camp film at time point 0.00-0.30 (t(10)=1.83, p=.05), 3.00-3.30 (trend, t(10)=1.62, p=.07) and 4.30-5.00 (t(10)=2.36, p=.02), but not at time point 1.30-2.00 (t(10)=.26, p=.40) compared to the abandonment film clip. Last, Participants did not report significant more continuous arousal after the positive film clip at time point 0.00-0.30 (t(10)=-1.23, p=.12), 1.30-2.00 (t(10)=-.73, p=.24), 3.00-3.30 (t(10)=-.79, p=.22) or 4.30-5.00 (t(10)=-.15, p=.44) compared to the neutral film clip.
Moreover, against expectation, no significant interaction effect of time * group (F(6, 24)=1.51, p=.22), film * group (F(6, 24)=.37, p=89) or time * film * group F(18, 72)=.77, p=.73) was found.
Total dissociation during the experiment was then tested as a covariate but the main effect was not significant (F(3, 7)=.05, p=.82), nor was there a significant interaction effect of time * dissociation (F(3, 21)=.42, p=.74), film * dissociation (F(3, 21)=.21, p=.89) or film * time * dissociation (F(9, 63)=.82, p=.60).
Recap self-reported continuous arousal
Concluding, BPD patients did not show delayed return to baseline of self-reported continuous arousal in response to positive (4b) or negative stimuli (5b). Neither did BPD patients show delayed return to baseline of self-reported continuous arousal in response to abandonment (6b, see fig. 4).
c. Physiological emotional arousal (HRV)
Data processing and assumptions
Physiological return to baseline was operationalized as physiological arousal (HRV) during the washouts of the film clips (see table 4 for the mean scores). HRV was calculated at four time points (0.00-0.30, 1.30-2.00, 3.00-3.30, 4.30-5.00) during the washout of the neutral, positive, abandonment and concentration camp film clips. Shapiro-Wilk’s test of normality indicated that the assumption of normality was not violated for HRV scores.
Hypotheses testing
A repeated-measures ANOVA was run with film type and time as within-subject factors and group as between-subjects factor. Mauchly’s test of sphericity indicated that the assumption of sphericity had not been violated for main effect of time (χ2(5)=9.42, p=.10) and film (χ2(5)=1.47,
p=.92).
There was no significant main effect of film F(3, 24)=.30, p=.83) or group (F(2,8)=.52, p=.62). But there was a significant main effect of time (F(3, 24)=3.73, p=.03). Paired-sample t-tests were run to analyse effects over time and showed that HRV significantly increased at time point 1.30-2.00 compared to time point 0.00-0.30 (t(10)=2.10, p=.03), but no differences were found between time points 1.30-2.00 - 3.00-3.30 (t(10)=.95, p=.18), and 3.00-3.30 - 4.30-5.00 (t(10)=.83, p=.21). Moreover, against expectation, no significant interaction effect of time * group (F(6, 24)=.64, p=.70), film * group (F(6, 24)=.43, p=85), time * film (F(9, 72)=.56, p=.83) or time * film * group F(18, 72)=.98, p=.50) was found.
Total dissociation during the experiment was then tested as a covariate but the main effect was not significant (F(1, 7)=2.30, p=.17), nor was there a significant interaction effect of time * dissociation (F(3, 21)=1.58, p=.22) or film * dissociation (F(3, 21)=1.24, p=.32). However, there was a significant interaction effect of film * time * dissociation (F(9, 63)=2.54, p=.02).
Independent sample t-tests were run to compare effects of the film clips over time between levels of dissociation on HRV and showed that higher levels of dissociation (cut-off= 12) significantly predicted higher levels of HRV during time point 1.30-2.00 of the washout of the neutral film
clip (t(9)=1.88, p=.05), but not at 0.00-0.30 (t(9)=.63, p=.27), 3.00-3.30 (t(9)=.12, p=.12) or 4.30-5.00 (t(9)=.75, p=.24). Furthermore, higher levels of dissociation (cut-off=12) trend significantly predicted higher levels of HRV during time point 4.30-5.00 of the washout of the positive film clip (t(9)=1.57, p=.08), but not at time point 0.00-0.30 (t(9)=.92, p=.19), 1.30-2.00 (t(9)=.83, p=.21) or 3.00-3.30 (t(9)=.96, p=.18). Additionally, dissociation did not predict HRV scores during washout of the concentration camp (0.00-0.30: t(9)=.25, p=.41; 1.30-2.00: t(9)=.39, p=.35; 3.00-3.30: t(9)=.12, p=.45; 4.30-5.00: t(9)=.12, p=.45) or abandonment (0.00-0.30: t(9)=.97, p=.18; 1.30-2.00: t(9)=.44, p=.34; 3.00-3.30: t(9)=.73, p=.24; 4.30-5.00: t(9)=.07, p=.47) film clips.
Recap physiological arousal
Concluding, BPD patients did not express delayed return to baseline of physiological arousal in response to positive (4c) or negative stimuli (5c). Neither did BPD patients express delayed return to baseline of physiological arousal in response to abandonment (6c, see fig. 3).
Exit interview
Two observations stood out the most from the exit interviews. 1) 8 out of 11 participants reported that they did not like Mr. Bean and did not thought it was funny which might explain why it did not induce positive emotion. 2) When asking participants what they felt and went through their minds during the film clips and washouts, ClC-PD patients and NpC expressed how the films had affected them and which aspects they recognized from their personal lives (e.g. “My father had survived a concentration camp”, “I recognize how the child was not wanted by the family which is similar to how I felt when I was younger”). BPD patients stated more about the film set up and whether they were interested in the film themes (“The film seems somewhat old and the characters did not act that well so the film did not influence me much”, “I was scared that it would be a movie about animal abuse so I was just relieved the topic was on something else”).
Table 5
Means and Standard deviations for Dissociation by Film clip and Group Film clips Dissociation Groups
NpC ClC-PD BPD Neutral Concentration Camp Abandonment Positive Unreal Hearing Body Pain Unreal Hearing Body Pain Unreal Hearing Body Pain Unreal Hearing Body Pain .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .00 (.00) .56 (1.12) 1.30 (2.59) 1.59 (2.70) .96 (1.91) 1.34 (2.68) 1.20 (2.39) 1.75 (2.58) 1.00 (2.01) 1.05 (2.10) 1.08 (2.17) 1.12 (2.23) 1.12 (2.23) 1.28 (2.55) 1.37 (2.74) 1.35 (2.71) 1.04 (2.07)
Note. Standard deviations are in brackets. Unreal= feeling that one’s surroundings are not real, hearing= problems
Discussion
The current study examined emotional reactivity and return to baseline in response to emotion-inducing film clips using a multi-method assessment of emotions in BPD patients as compared to ClC-PD and nonpatient controls. The main finding of this study was that BPD patients did not express heightened subjective or physiological emotional reactivity or delayed return to baseline in response to positive, disorder related (abandonment), or disorder nonrelated negative stimuli. On the contrary, ClC-PD patients expressed heightened subjective emotional reactivity and delayed return to baseline in response to the disorder nonrelated negative stimulus (concentration camp).
Consistent with the majority of research to date, our findings do not support Linehan’s biosocial theory (1993) of general heightened emotional reactivity and delayed return to baseline in BPD. Furthermore, in theory the results of this study do not contradict Lobbestael & Arntz (2015) proposition that emotional reactivity in BPD might be specific to disorder related themes such as child abuse by primary caregivers. Possibly, abandonment – the proposed disorder related theme used in this study – is not a trigger for heightened emotional reactivity in BPD or the intense emotional response is unique related to triggers of child abuse by primary caregivers.
The findings of this study imply that BPD is not characterized by heightened emotional reactivity and delayed return to baseline. An alternative explanation for the finding that BPD is not characterized by heightened emotional reactivity and delayed return to baseline is related to the choice of emotion-inducing stimuli. First, a possibility is that the disorder specific film clip did not trigger fear of abandonment in BPD patients. In the film clip the woman abandons her husband out of choice, and the child is taken care of by his biological mother after his foster family abandons him. Also, both the child and the women have ambivalent roles being both victim and perpetrator, which might have hampered identification with the characters and inhibited the intensity of the emotional response (and thus heightened emotional reactivity). Second, a possibility is that BPD patients were able to distance themselves from the standardized film clips as a defense mechanism to regulate their emotional response. This suggestion emerged from the short qualitative interview held at the end of the experiment. The researcher noticed that after asking what went through participants’ minds during and after the film clips, BPD patients mostly referred to the setup of the films were ClC-PD patients referred to how the films affected them personally. This focus on practical issues of BPD patients might have functioned as a coping mechanism and inhibited the intensity of the emotional response (and thus
heightened emotional reactivity).
Moreover, conclusions should be taken with extreme caution considering the sample size was very small, and well below the sample size planned on the basis of a power analysis. The
available time for recruiting participants was limited by the format and practical agreements of the master thesis. In total the recruitment took place for ten weeks during which the researcher screened all incoming intakes of the participating health care institution, approached eligible participants, and conducted the experiment. It turned out to be difficult to reach and motivate eligible people to participate in the study: most did not reply to e-mail nor answered the phone and a few were unpleased that they were contacted by the researcher. On top of that five people did not show up for the appointment or decided at the beginning of the experiment not to participate after all. All of the above resulted in a very small sample size and an underpowered study, which increased the risk that true differences between groups have remained undetected by this experiment. Possibly, BPD is in fact characterized by heightened emotional reactivity and delayed return to baseline in response to abandonment but due to low statistical validity the hypothesis was incorrectly rejected by this study.
Additionally there were a few limitations to this study. The first limitation was the operationalization of return to baseline. After each film clip participants underwent a washout period of five minutes during which they were asked to relax, sit still and stare at a black screen. This was designed so that participants would not be distracted by other factors during washout and the extinction of the emotional response remained uninfluenced. However, several
participants reported that they felt insecure, upset and angry during the washout periods not knowing how much time there was left before the following film would start. This could have had its effects on the results, and might have functioned as a distractor itself. The second limitation was that the current study was unable to extract valid facial expressions from the data with facial expression recognition software (and time limitations withheld analysis by hand). This is unfortunate since it is the one physiological measure of emotion that can differentiate between valences and is therefore important in obtaining a complex understanding of emotional response in BPD. Lastly, as mentioned before the small sample size is a limitation of this study.
Future research should continue studying emotional reactivity and return to baseline in response to differently valenced stimuli using a multi-method approach of emotional response and both a patient- and nonpatient comparison group. More research with a sufficient sample size is needed before conclusions can be drawn on emotional reactivity and return to baseline in relation to abandonment. Future research could make use of personalized stimuli or a film clip in which a female character is the victim and abandoned by someone else. Possibly, these options could trigger personal fears of abandonment and induce heightened emotional reactivity and delayed return to baseline in BPD patients. Furthermore, for a complete assessment of emotional response it is suggested to add facial expressions, and to analyze this data by hand. This is a time
consuming process, but also more flexible in extracting valid facial expressions from the data under different conditions. Lastly, research on return to baseline could depict an hourglass during the washout periods to give the participants a little more grip and therewith reducing influences of uncertainty and insecurity.
The current study was the first study researching emotional reactivity and return to baseline assessing both subjective and physiological measures of emotion in response to a disorder related stimulus abandonment in borderline personality disorder. Patients with BPD did not show
subjective or physiological heightened emotional reactivity and delayed return to baseline in response to abandonment. Concluding, our findings did not support Linehan’s biosocial theory (1993) but our findings should be taken with great caution given the small sample size.
Nevertheless, future research can build on the design, insights and suggestions for future directions from this experiment. Therefore this study helped gain a little more insight in understanding emotional responding in borderline personality disorder and contributed to improving existing treatment options for this severe disorder.
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