Determination of First Object Relations and Emotion Regulation Difficulties in Borderline Personality Disorder with Objective and Projective Methods

Abstract

Evaluation of the disorders in the personality organization of the individual is only possible by examining the object relations functions, and it is known that the elimination of emotion regulation difficulties (ERD) has a central role in the treatment of borderline personality disorder (BPD). Therefore, this study, in which objective and projective methods were used together, was designed to determine the ERD of BPD patients and the relationship between the patients' object relations and emotion regulation difficulties. It is thought that the results of the study can be useful in the psychotherapy processes of BPD patients. For this purpose, the Sociodemographic Data Form, Rorschach Test, and Emotion Regulation Difficulty Scale developed by the researchers were applied to 37 individuals diagnosed with Borderline Personality Disorder according to DSM-5 criteria and 37 individuals who did not have any psychiatric diagnosis as a result of their psychiatric examination by a psychiatrist. As a result of the study, it was determined that there was a significant relationship between BPD and ERD, and this relationship could be determined through the Rorschach test, and it was determined that BPD constituted 55% of the variance of ERD. ERD, which can have significant disruptive effects on the lives of borderline patients, was associated with the patients' lack of satisfaction and inclusion in their relations with their first object, which is usually their parents, and it was determined negative qualities of first objects accounted for 23% of the variance of difficulty in emotion regulation. It is thought that the results of the study may contribute to the acceleration of the solution of interpersonal problems, which have a close relationship with ERD, of the patients and the standardization of the Rorschach Test.

Keywords

• borderline personality disorder
• object relations
• first object
• emotion regulation
• Rorschach Test

Borderline Kişilik Bozukluğunda İlk Nesne İlişkileri ve Duygu Düzenleme Güçlüğünün Objektif ve Projektif Yöntemlerle Belirlenmesi

Öz

Bireyin kişilik örgütlenmesindeki bozuklukların değerlendirilmesi ancak nesne ilişkileri fonksiyonların incelenmesiyle tam anlamıyla mümkün olmakta ve duygu düzenleme güçlüğünün (DDG) giderilmesinin borderline kişilik bozukluğu (BKB) tedavisinde merkezi bir role sahip olduğu bilinmektedir. Bu doğrultuda hem BKB hastalarının duygu düzenleme güçlüklerinin hem de hastaların nesne ilişkilerinin duygu düzenleme güçlükleri ile olan ilişkisinin belirlenmesi amaçlanarak objektif ve projektif yöntemlerin bir arada kullanıldığı bu çalışma tasarlanmıştır. Çalışma sonuçlarından BKB hastalarının psikoterapi süreçlerinde faydalanılabileceği düşünülmektedir. Bu amaçla psikiyatri uzmanı tarafından, DSM-5 ölçütlerine göre BKB tanısı alan 37 birey ile psikiyatrik muayenesi sonucunda herhangi bir psikiyatrik tanı almamış 37 bireye araştırmacılar tarafından geliştirilmiş olan Sosyodemografik Veri Formu, Rorschach Testi, Duygu Düzenleme Güçlüğü Ölçeği uygulanmıştır. Çalışma sonucunda BKB ile DDG arasında anlamlı bir ilişki olduğu ve bu ilişkinin Rorschach testi aracılığıyla belirlenebildiği tespit edilmiş olup BKB’nin DDG varyansının %55’ini oluşturduğu belirlenmiştir. Borderline hastaların yaşamları üzerinde önemli bozucu etkilerde bulunabilen duygu düzenleme güçlüğünün, hastaların genellikle ebeveynleri olan ilk nesneleriyle ilişkilerindeki doyum ve kapsanma yetersizliğiyle ilişkili olduğu olup ilk nesnelere dair olumsuz niteliklerin DDG varyansının %23’ünü oluşturduğu tespit edilmiştir. Çalışma sonuçlarının hastaların, DDG ile yakından ilişkili olan, kişilerarası problemlerinin çözümünün hızlanmasına ve projektif bir ölçüm aracı olan Rorschach Testi’nin standardizasyonu adına katkı sağlayabileceği düşünülmektedir.

Anahtar Kelimeler

• borderline kişilik bozukluğu
• nesne ilişkileri
• ilk nesne
• duygu düzenleme
• Rorschach Testi

Kaynakça

1. Adrian M, Zeman J, Erdley C, Lisa L, Sim L (2011) Emotional dysregulation and interpersonal difficulties as risk factors for nonsuicidal self-injury in adolescent girls. J Abnorm Child Psychol, 39: 389-400.
2. Aldao A, Nolen-Hoeksema S, Schweizer S (2010) Emotion-regulation strategies across psychopathology: A meta-analytic review. Clin Psychol Rev, 30: 217–237.
3. Anzieu D, & Chabert C (2011) Projektif yöntemler (Çeviri ed. B Kolbay). İstanbul, Bağlam Yayınları.
4. Arens EA, Grabe HJ, Spitzer C, Barnow S (2011) Testing the biosocial model of borderline personality disorder: Results of a prospective 5-year longitudinal study. Personal Ment Health, 5: 29– 42.
5. Bandelow B, Krause J, Wedekind D, Broocks A, Hajak G, & Ruther E (2005) Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with borderline personality disorder and healthy controls. Psychiatry Res, 134 169– 179.
6. Bland AR, Tudor G, & Whitehouse DM (2007) Nursing care of inpatients with borderline personality disorder. Perspect Psychiatr Car, 43: 204-212.
7. Boucher MÈ, Pugliese J, Allard‐Chapais C, Lecours S, Ahoundova L, Chouinard R, Gaham S (2017) Parent–child relationship associated with the development of borderline personality disorder: a systematic review. Personal Ment Health, 11: 229-255.
8. Burns EE, Jackson JL, Harding HG (2010) Child maltreatment, emotion regulation, and posttraumatic stress: The impact of emotional abuse. Journal of Aggression, Maltreatment & Trauma, 19: 801-819.

9. Calkins SD, Hill A (2007) Caregiver Influences on Emerging Emotion Regulation: Biological and Environmental Transactions in Early Development. Gross, J. J. (Ed.). handbook of Emotion Regulation. New York: The Guilford Press.
10. Carpenter RW, Trull TJ (2013) Components of emotion dysregulation in borderline personality disorder: A review. Curr Psychiatry Rep, 15: 1-8. http:// dx.doi.org/10.1007/s11920-012-0335-2.
11. Chevans JS, Strunk DR, Chiriki L (2012) A comparison of three theoretically important constructs: What accounts for symptoms of borderline personality disorder? J Clin Psychol, 68: 477-486.
12. Cloitre M, Scarvalone P. Difede J (1997) Posttraumatic stress disorder, self- and interpersonal dysfunction among sexually retraumatized women. J Trauma Stress, 10: 437-452.
13. Denham S (2003) Family health: A framework for nursing. USA: Davis Company.
14. Dimaggio G, Popolo R, Montano A, Velotti P, Perrini F, Buonocore L, Salvatore G (2017) Emotion dysregulation, symptoms, and interpersonal problems as independent predictors of a broad range of personality disorders in an outpatient sample. Psychol Psychother, 90: 586-599.
15. Dixon-Gordon KL, Turner BJ, Rosenthal MZ, Chapman AL (2017) Emotion regulation in borderline personality disorder: an experimental investigation of the effects of instructed acceptance and suppression. Behavior therapy, 48: 750-764.
16. Ebner-Priemer UW, Houben M, Santangelo P., Kleindienst N, Tuerlinckx F, Oravecz, Z, et al. (2015) Unraveling affective dysregulation in borderline personality disorder: A theoretical model and empirical evidence. J Abnorm Psychol, 124: 186- 198. https://doi.org/10.1037/abn0000021
17. Euler S, Nolte T, Constantinou M, Griem J, Montague PR, Fonagy P (2021) Interpersonal problems in borderline personality disorder: associations with mentalizing, emotion regulation, and impulsiveness. J Pers Disord, 35: 177-193.
18. Faraji H, Tezcan AE (2022) Borderline kişilik bozukluğu. İstanbul, Nobel Akademik Yayıncılık.
19. Faraji H, Güler K. (2021) Borderline personality traits and self handicapping. Int J Curr Res, 13: 17683-17689. DOI: https://doi.org/10.24941/ijcr.41401.06.2021
20. Faraji H. (2021) Borderline kişilik bozukluğunun ergenlik döneminde belirlenmesine dair bir değerlendirme, OPUS Toplum Araştırmaları Dergisi, 18: 7141-7166. DOI: 10.26466/opus. 898571
21. Faraji H, Güler K (2021) Borderline personality features and jealousy traits in university students, Aydın İnsan ve Toplum Dergisi, 2:137-154.
22. Farrell JM, Shaw IA (1994) Emotional awareness training: A prerequisite to effective cognitive-behavioral treatment of borderline personality disorder. Cogn Behav Pract, 1: 71-91. https://doi.org/10.1016/S1077-7229(05)80087-2
23. Finkelhor D, Ormrod R, Turner H, Holt M (2009) Pathways to poly-victimization. Child Maltreatment, 14: 316-329. https://doi.org/10.1177/1077559509347012
24. Fletcher K, Parker G, Bayes A, Paterson A, McClure G (2014) Emotion regulation strategies in bipolar II disorder and borderline personality disorder: Differences and relationships with perceived parental style. J Affect Disord , 157: 52– 59. https://doi.org/10.1016/j.jad.2014.01.001
25. Frank H, Hoffman N (1986) Borderline empathy: An empirical investigation. Compr Psychiatry, 27: 387– 395. https://doi.org/10.1016/0010-440X(86)90015-5
26. George D, Mallery P (2010) SPSS for windows a step by step: A Simple Guide and Reference. Pearson Education, Inc.
27. Ghiassi V, Dimaggio G, Brune M (2010) Dysfunctions in understanding other minds in borderline personality disorder: A study using cartoon picture stories. Psychother Res, 20: 657– 667. https://doi.org/10.1080/10503307.2010.501040
28. Gratz KL, Roemer L (2004) Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. J Psychopathol Behav Assess, 26: 41-54. https://doi.org/10.1023/B:JOBA.0000007455.08539.94
29. Gratz KL, Rosenthal MZ, Tull MT, Lejuez CW, Gunderson JG (2009) An experimental investigation of emotion dysregulation in borderline personality disorder. Personal Disord,1: 18–26. https://doi.org/10.1037/1949-2715.S.1.18
30. Hallquist MN, Hipwell AE, Stepp SD (2015) Poor self-control and harsh punishment in childhood prospectively predict borderline personality symptoms in adolescent girls. J Abnorm Psychol, 124: 549–64. https://doi.org/10.1037/abn0000058
31. Hoch P, Polatin P (1949) Pseudoneurotic forms of schizophrenia. Psychiatr Q, 23(2), 248-276. https://doi.org/10.1007/BF01563119 Hogan R (2007) Personality and the fate of organizations, Mahwah, NJ: Lawrence Erlbaum Associates.
32. Houben M, Claes L, Sleuwaegen E, Berens A, Vansteelandt K (2018) Emotional reactivity to appraisals in patients with a borderline personality disorder: a daily life study. Borderline Personal Disord Emot Dysregul, 5: 18-32. https://doi.org/10.1186/s40479-018-0095-7
33. Huang J, Napolitano LA, Wu J, Yang Y, Xi Y, Li Y et al. (2014) Childhood experiences of parental rearing patterns reported by Chinese patients with borderline personality disorder. Int J Psychol, 49: 38– 45. https://doi.org/10.1002/ijop.12007
34. Hughes AE, Crowell SE, Uyeji L, Coan JA (2012) A developmental neuroscience of borderline pathology: emotion dysregulation and social baseline theory. J Abnorm Child Psychol, 40: 21–33.
35. Huprich SK (Ed.). (2006) Rorschach assessment of the personality disorders. Routledge.
36. İkiz T (2001) Rorschach Testinin psikanalitik yorumu-II, Kodlama ve uygulama, Düş/Düşün, 6, İstanbul, Bağlam Yayınları.
37. İkiz T (2002) Rorschach Testinin psikanalitik yorumu-II, Erişkin psikopatolojisinin değerlendirilmesi, Düş/Düşün, 11, İstanbul, Bağlam Yayınları.
38. İkiz T, Düşgör BP, Atak İE, Mete L, Kalem E (2013) Rorschach kodlama kitabı-III, yaşlı normları (1.Baskı), İstanbul, Bağlam Yayınları.
39. İkiz T, Düşgör BP, Zabcı N, Yavuz AE, Atak İE, Ataç S, ve ark. (2007) Rorschach kodlama kitabı-I, ergen normları (1.Baskı), İstanbul, Bağlam Yayınları.
40. İkiz T, Yavuz AE, Atak İE, Düşgör BP, Zabcı N. (2009) Rorschach kodlama kitabı-II, yetişkin normları (1.Baskı), İstanbul, Bağlam Yayınları.
41. Kahya Y, Munguldar K (2022) Difficulties in emotion regulation mediated the relationship between reflective functioning and borderline personality symptoms among non-clinical adolescents. Psychol Rep, https://doi.org/10.1177/00332941211061072
42. Kaur M, Sanches M (2022) Parenting Role in the Development of Borderline Personality Disorder. Psychopathology, 1-8. DOI: 10.1159/000524802
43. Kernberg OF (1985) Borderline conditions and pathological narcissism. Rowman & Littlefield.
44. Kim J, Cicchetti D (2010) Longitudinal pathways linking child maltreatment, emotion regulation, peer relations, and psychopathology. J Child Psychol Psychiatry, 51: 706-716. https://doi.org/10.1111/j.1469-7610.2009.02202.x
45. Klonsky ED (2008) What is emptiness? Clarifying the 7th criterion for borderline personality disorder. J Pers Disord, 22: 418-426.
46. Kobak RR, Sceery A (1988) Attachment in late adolescence: Working models, affect regulation, and representations of self and others. Child Dev, 59: 135-146.
47. Kring AM, Sloan DM (2009) Emotion regulation and psychopathology. A Transdiagnostic approach to etiology and treatment. New York, NY: Guilford Press.
48. Kuo JR, Khoury JE, Metcalfe R, Fitzpatrick S, Goodwill A (2015) An examination of the relationship between childhood emotional abuse and borderline personality disorder features: The role of difficulties with emotion regulation. Child Abuse Negl, 39: 147-155. https://doi.org/10.1016/j.chiabu.2014.08.008
49. Levine D, Marziali E, Hood J (1997) Emotion processing in borderline personality disorders. J Nerv Ment Dis, 185: 240–246.
50. Lilly MM, London MJ. Bridgett DJ. (2014) Using SEM to examine emotion regulation and revictimization in predicting PTSD symptoms among childhood abuse survivors. Psychol Trauma, 6: 644-651. https://doi.org/10.1037/a0036460
51. Linehan MM (1993) Cognitive-behavioral treatment of borderline personality disorder. New York: The Guildford Press.
52. Lutz J, Gross RT, Vargovich AM (2018) Difficulties in emotion regulation and chronic pain-related disability and opioid misuse. Addictive behaviors, 87: 200-205.
53. Marques R, Monteiro F, Canavarro MC, Fonseca A (2018) The role of emotion regulation difficulties in the relationship between attachment representations and depressive and anxiety symptoms in the postpartum period. J Affect Disord, 238: 39-46. https://doi.org/10.1016/j.jad.2018.05.013
54. Masterson JF (2008) Borderline yetişkinlerde psikoterapi (Çeviri ed. H Macit, M Macit) İstanbul, Litera Yayıncılık Merza K, Papp G, Szabó IK (2015) The role of childhood traumatization in the development of borderline personality disorder in Hungary. Eur J Psychiatr, 29: 105– 118.
55. Mikulincer M, Florian V. Wells A (1993) Attachment styles, coping strategies, and posttraumatic psychological distress: The impact of the Gulf War in Israel. J Pers Soc Psychol, 64: 817-826.
56. Murphy A, Steele M, Dube SR, Bate J, Bonuck K, Meissner P, et al (2014). Adverse childhood experiences (ACEs) questionnaire and adult attachment interview (AAI): Implications for parent child relationships. Child Abuse Negl, 38: 224–233.
57. Nanni V, Uher R, Danese A (2012) Childhood maltreatment predicts unfavorable course of illness and treatment outcome in depression: a meta-analysis. Am J Psychiatry, 169: 141-151.
58. Ntshingila N, Poggenpoel M, Myburgh CPH, Temane A (2016) Experiences of women living with borderline personality disorder. Health SA, 21:110-119. DOI: 10.1016/j.hsag.2016.01.001
59. Pon RS, Kashdan TB, DeWall CN, Savostyanova AL, Nathaniel M, Fincham, FD (2012). Emotion differentiation moderates aggressive tendencies in angry people: A daily diary analysis. Emotion, 12: 326–337. https://doi.org/ 10.1037/a0025762
60. Quattrini G, Pini L, Pievani M, Magni LR, Lanfredi M, Ferrari C. et al. (2019) Abnormalities in functional connectivity in borderline personality disorder: Correlations with metacognition and emotion dysregulation. Psychiatry Res Neuroimaging, 283: 118-124.
61. Reynolds V (1998) Axis II comorbidity of borderline personality disorder. Compr Psychiatry, 39: 296-302. DOI: 10.1016/s0010-440x(98)90038-4.
62. Rugancı, RN, Gençöz T (2010) Psychometric properties of Turkish version of Diffuculties in Emotion Regulation Scale. J Clin Psychol, 66: 442-455. https://doi.org/10.1002/jclp.20665
63. Sauer C, Arens EA, Stopsack M, Spitzer C, Barnow S (2014) Emotional hyper-reactivity in borderline personality disorder is related to trauma and interpersonal themes. Psychiatry Res, 220: 468-476. https://doi.org/10.1016/j.psychres.2014.06.041
64. Schmitz M, Bertsch K, Löffler A, Steinmann S, Herpertz SC, Bekrater-Bodmann R (2021) Body connection mediates the relationship between traumatic childhood experiences and impaired emotion regulation in borderline personality disorder. Borderline Personal Disord Emot Dysregul, 8: 1-13. https://doi.org/10.1186/s40479-021-00157-7
65. Soloff PH, Pruitt P, Sharma M, Radwan J, White R, Diwadkar VA (2012) Structural brain abnormalities and suicidal behavior in borderline personality disorder. J Psychiatr Res. 46: 516–25.
66. Soykan A (2019). Sınır kişilik özelliği deneyimleyen bireylerin bağlanma stilleri ile duygu farkındalığı ve duygu düzenleme güçlüğü düzeylerinin incelenmesi (yüksek lisans tezi). Ankara, Başkent Üniversitesi.
67. Sroufe LA (2005) Attachment and development: A prospective, longitudinal study from birth to adulthood. Attach Hum Dev, 7: 349–367. https://doi.org/10.1080/14616730500365928
68. Staebler K, Helbing E, Rosenbach, C, Renneberg, B (2011) Rejection sensitivity and borderline personality disorder. Clinical psychology & psychotherapy, 18: 275-283. https://doi.org/10.1002/cpp.705
69. Stanton AL, Kirk SB, Cameron CL, Danoff-Burg S (2000) Coping through emotional approach: scale construction and validation. J Pers Soc Psychol, 78: 1150–1169. https://doi.org/10.1037/0022-3514.78.6.1150
70. Stevens NR, Gerhart J, Goldsmith RE, Heath NM, Chesney SA, Hobfoll SE (2013) Emotion regulation difficulties, low social support, and interpersonal violence mediate the link between childhood abuse and posttraumatic stress symptoms. Behavior Therapy, 44: 152-161.
71. Varma S, Traynor J, Fitzpatrick S (2022) A mixed methods examination of emotional expression and its impact on emotion regulation effectiveness in borderline personality disorder. J Behav Ther Exp Psychiatry, 75: 101712.
72. Weiss NH, Forkus SR, Contractor AA, Schick MR (2018) Difficulties regulating positive emotions and alcohol and drug misuse: A path analysis. Addict Behav, 84: 45-52.
73. Winnicott D (2019) Oyun ve gerçeklik. 4. Basım. İstanbul: Metis Yayınları. (1971)
74. Winsper C, Lereya ST, Marwaha S, Thompson A, Eyden J, Singh SP (2016) The aetiological and psychopathological validity of borderline personality disorder in youth: a systematic review and meta-analysis. Clin Psychol Rev, 44: 13–24.
75. Winsper C, Zanarini M, Wolke D (2012) Prospective study of family adversity and maladaptive parenting in childhood and borderline personality disorder symptoms in a non-clinical population at 11 years. Psychol Med, 42: 2405–2420.
76. Winsper C (2018) The aetiology of borderline personality disorder (BPD): contemporary theories and putative mechanisms. Curr Opin Psychol, 21: 105–110.
77. Zabcı N (2012) Sınır patolojilerde nefretin kökeni üzerine. Yansıtma Psikopatoloji ve Projektif Testler Dergisi. 18: 21-26.
78. Zaki LF, Coifman KG, Rafaeli E, Berenson KR, Downey G (2013) Emotion differentiation as a protective factor against nonsuicidal self-injury in borderline personality disorder. Behavior Therapy, 44: 529–540. https://doi.org/10.1016/j. beth.2013.04.008.
79. Zeigler-Hill V, Abraham J (2006) Borderline personality features: Instability of self-esteem and affect. J Soc Clin Psychol, 6: 668–687.