Letter to the Editor Received: December 15, 2013 Accepted after revision: June 4, 2014 Published online: October 16, 2014
Psychother Psychosom 2014;83:377–378 DOI: 10.1159/000365110
Table 1. Partial correlations between EI and cluster C and borderline personality traits after controlling for the global severity of psychopathology
Emotional Inhibition in Personality Disorders Raffaele Popolo a Paul H. Lysaker e, f Giampalo Salvatore a Antonella Montano b Luisa Buonocore a Laura Sirri c Antonella Imbimbo d Giancarlo Dimaggio a
PD traits
EI dimensions verbal timidity inhibition
a Centro
di Terapia Metacognitiva Interpersonale, and A.T. Beck, Rome, c Laboratory of Psychosomatics and Clinimetrics, Department of Psychology, University of Bologna, Bologna, and d Studio di Terapia Cognitiva, Reggio Emilia, Italy; e Roudebush VA Medical Center, and f Indiana University, Indianapolis, Ind., USA b Istituto
Avoidant 0.36** Dependent 0.11 Obsessivecompulsive 0.03 Borderline –0.04
0.32** 0.24* 0.10 –0.10
disguise of feelings
0.30** 0.06 –0.01 –0.07
Selfcontrol
Total
0.22 0.03
0.42** 0.15
–0.09 0.00 –0.30** –0.18
* p < 0.01; ** p < 0.0001. Emotional inhibition (EI) refers to the tendency to suppress the expression of one’s own feelings to others [1]. EI is considered an underlying cause of psychopathology and may adversely impact psychological and health outcomes [1, 2]. Little is known, however, about the correlates and potential causes of EI. One putative factor underlying the tendency to inhibit emotional expression is the presence of a personality disorder (PD). PD sufferers may suppress their emotions because of a fear of losing control over their feelings or that disclosing feelings will have negative social consequences [3–5]. Persons with avoidant PD may be inclined to suppress their emotions because of a fear of negative consequences, while persons with obsessive-compulsive PD may suppress emotions because of a negative view of emotional display [3]. Dependent traits may contribute to thoughts that disclosing negative feelings will reinforce others’ negative ideas of the individual and lead them to withhold help. People with borderline PD may instead be less prone to inhibit their feelings. To date, the impact of PD on EI has been largely understudied. Evidence states that behavioral inhibition is a feature of cluster C PDs [5–7]. Studies on inhibition have mostly focused on its behavioral correlates, but it is necessary to understand the cognitive processes which lead people to inhibit their feelings and hesitate to disclose them publicly. Furthermore, the assessment of tendencies to suppress feelings is an important issue for treatment planning, since psychotherapy may reduce the negative impact of emotional suppression on health and psychological functioning [2]. The aim of this study was to assess the relationship between EI and cluster C and borderline personality traits. We also included a measure of symptoms such as depression, anxiety and hostility as a covariate to rule out the possibility that any significant relationships between EI and personality traits could be accounted for by the presence of heightened specific symptoms often present in PDs. A total of 138 adults enrolled in outpatient treatment in two private clinics in Rome were recruited. Exclusion criteria were psychosis, mental retardation and active substance abuse.
© 2014 S. Karger AG, Basel 0033–3190/14/0836–0377$39.50/0 E-Mail [email protected] www.karger.com/pps
Following written informed consent and prior to the beginning of treatment, participants completed the Emotional Inhibition Scale (EIS) [1] and the Symptom Checklist-90 (SCL-90) [8]. The EIS is a 16-item questionnaire including 4 subscales: ‘verbal inhibition’, ‘disguise of feelings’, ‘timidity’, and ‘self-control’. Evidence of its psychometric properties has been reported elsewhere [1]. Subjects also underwent the Structured Clinical Interview for Personality Disorders (SCID-P) [9]. Two-tailed partial correlations were performed to assess the relationship between the number of SCID-P avoidant, dependent, obsessive-compulsive and borderline traits and EIS total and subscale scores, while controlling for the SCL-90 global severity index (GSI). The GSI was included as a covariate to rule out the possibility that any observed relationship was just the result of heightened levels of psychopathology. To avoid type I errors given the number of correlations calculated, the p level was set at 0.01. The mean age of the sample was 36.8 years (±9.7; range 19–66); 76 subjects (55.1%) were women and 62 (44.9%) were men. Table 1 shows the relationships between EIS scores and SCID-P traits. For exploratory purposes we correlated the EIS subscales with the depression, anxiety and hostility subscales of the SCL-90. These revealed no significant correlations at the 0.01 level. Although the correlational nature of this study does not allow any conclusions regarding causality, our results may offer some implications for a better understanding of the clinical manifestations of PDs and the refinement of their treatment. Avoidant traits were associated with EI. Avoidant traits may be a significant risk factor for the development of EI, but it cannot be excluded that EI contributes to the development of avoidant traits. This issue cannot be solved here given the correlational nature of this study and is a matter for future research. Given the expectation that others will reject or criticize
Giancarlo Dimaggio Centro di Terapia Metacognitiva Interpersonale Piazza dei Martiri di Belfiore, 4 IT–00195 Roma (Italy) E-Mail gdimaje @ libero.it
them, people with avoidant traits are afraid to disclose the nature of their feelings and try to suppress signs that would reveal their drives. The reduction of EI through specific psychotherapeutic strategies may assist people with avoidant traits to disclose painful feelings and develop relationships with others that support healthy functioning. Dependent traits were marginally associated with EIS ‘timidity’. People with high levels on this subscale find it difficult to speak up for their rights and let others take advantage of them. Dependent traits could prevent subjects from developing assertive skills. This finding seems to support the inclusion of assertive training among the therapeutic ingredients in the treatment of dependent personality. No dimension of EI, as assessed by the EIS, was found to be significantly associated with obsessive-compulsive traits. A previous study on early maladaptive schemas found obsessive-compulsive PD unrelated to the cognitive schema of EI [10]. Different underlying mechanisms could explain the seemingly similar tendency to suppress emotional expression in subjects with cluster C PDs. Avoidant and dependent traits may be associated with conscious inhibition of perceived emotional states, as operationalized by the EIS, because of fear of being abandoned or losing support. A thorough understanding of the relationship between EI and personality traits may help in identifying similarities and boundaries between different PDs. The negative correlation between EIS ‘selfcontrol’ and borderline traits is consistent with the impulsive tendencies of patients with borderline PD [9]. Of note, the magnitude of the correlations was small, except the association between avoidant traits and EI. Future studies including people with fully developed cluster C diagnoses excluding cooccurrence with other PDs may find more robust associations than just exploring the correlates of traits. Additionally, one limitation of the use of the SCL-90 GSI is that it might tap into a response style and not merely symptom severity. Our findings point to further studies aimed at assessing which factors (e.g. anxiety, depressive symptoms, dysfunctional interpersonal patterns) may mediate or moderate the association between EI and PD. Furthermore, the observed relationship between EI and
378
Psychother Psychosom 2014;83:377–378 DOI: 10.1159/000365110
avoidant PD suggests that EI may be considered a treatment target. Future studies should examine whether the refinement of psychotherapeutic strategies for the components of EI improve the outcome for PDs, and in particular for avoidant PD. Disclosure Statement The authors have no conflicts of interest to declare.
References 1 Grandi S, Sirri L, Wise TN, Tossani E, Fava GA: Kellner’s Emotional Inhibition Scale: a clinimetric approach to alexithymia research. Psychother Psychosom 2011;80:335–344. 2 Pennebaker JW, Kiecolt-Glaser JK, Glaser R: Disclosure of traumas and immune function: health implications for psychotherapy. J Consult Clin Psychol 1988;56:239–245. 3 Dimaggio G, Salvatore G, Fiore D, Carcione A, Nicolò G, Semerari A: General principles for treating personality disorder with a prominent inhibitedness trait: towards an operationalizing integrated technique. J Pers Disord 2012;26:63–83. 4 Spinhoven P, Bamelis L, Molendijk M, Haringsma R, Arntz A: Reduced specificity of autobiographical memory in cluster C personality disorders and the role of depression, worry, and experiential avoidance. J Abnorm Psychol 2009;118:520–530. 5 Farmer RF, Nelson-Gray RO: Anxiety, impulsivity, and the anxious-fearful and erratic-dramatic personality disorders. J Res Pers 1995;29:189–207. 6 Pastor MC, Ross SR, Segarra P, Montañés S, Poy R, Moltó J: Behavioral inhibition and activation dimensions: relationship to MMPI-2 indices of personality disorder. Pers Individ Dif 2007;42:235–245. 7 Livesley WJ, Jang KL, Vernon PA: Phenotypic and genetic structure of traits delineating personality disorder. Arch Gen Psychiatry 1998;55:941–948. 8 Derogatis LR: SCL-90-R: Administration, Scoring, and Procedures Manual, ed 3. Minneapolis, National Computer Systems, 1994. 9 First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS: Structured Clinical Interview for DSM-IV Axis II Personality Disorders, (SCID-II). Washington, American Psychiatric Press, 1997. 10 Jovev M, Jackson HJ: Early maladaptive schemas in personality disordered individuals. J Pers Disord 2004;18:467–478.
Popolo /Lysaker /Salvatore /Montano / Buonocore /Sirri /Imbimbo /Dimaggio
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Psychother Psychosom 2014;83:377–378 DOI: 10.1159/000365110
Table 1. Partial correlations between EI and cluster C and borderline personality traits after controlling for the global severity of psychopathology
Emotional Inhibition in Personality Disorders Raffaele Popolo a Paul H. Lysaker e, f Giampalo Salvatore a Antonella Montano b Luisa Buonocore a Laura Sirri c Antonella Imbimbo d Giancarlo Dimaggio a
PD traits
EI dimensions verbal timidity inhibition
a Centro
di Terapia Metacognitiva Interpersonale, and A.T. Beck, Rome, c Laboratory of Psychosomatics and Clinimetrics, Department of Psychology, University of Bologna, Bologna, and d Studio di Terapia Cognitiva, Reggio Emilia, Italy; e Roudebush VA Medical Center, and f Indiana University, Indianapolis, Ind., USA b Istituto
Avoidant 0.36** Dependent 0.11 Obsessivecompulsive 0.03 Borderline –0.04
0.32** 0.24* 0.10 –0.10
disguise of feelings
0.30** 0.06 –0.01 –0.07
Selfcontrol
Total
0.22 0.03
0.42** 0.15
–0.09 0.00 –0.30** –0.18
* p < 0.01; ** p < 0.0001. Emotional inhibition (EI) refers to the tendency to suppress the expression of one’s own feelings to others [1]. EI is considered an underlying cause of psychopathology and may adversely impact psychological and health outcomes [1, 2]. Little is known, however, about the correlates and potential causes of EI. One putative factor underlying the tendency to inhibit emotional expression is the presence of a personality disorder (PD). PD sufferers may suppress their emotions because of a fear of losing control over their feelings or that disclosing feelings will have negative social consequences [3–5]. Persons with avoidant PD may be inclined to suppress their emotions because of a fear of negative consequences, while persons with obsessive-compulsive PD may suppress emotions because of a negative view of emotional display [3]. Dependent traits may contribute to thoughts that disclosing negative feelings will reinforce others’ negative ideas of the individual and lead them to withhold help. People with borderline PD may instead be less prone to inhibit their feelings. To date, the impact of PD on EI has been largely understudied. Evidence states that behavioral inhibition is a feature of cluster C PDs [5–7]. Studies on inhibition have mostly focused on its behavioral correlates, but it is necessary to understand the cognitive processes which lead people to inhibit their feelings and hesitate to disclose them publicly. Furthermore, the assessment of tendencies to suppress feelings is an important issue for treatment planning, since psychotherapy may reduce the negative impact of emotional suppression on health and psychological functioning [2]. The aim of this study was to assess the relationship between EI and cluster C and borderline personality traits. We also included a measure of symptoms such as depression, anxiety and hostility as a covariate to rule out the possibility that any significant relationships between EI and personality traits could be accounted for by the presence of heightened specific symptoms often present in PDs. A total of 138 adults enrolled in outpatient treatment in two private clinics in Rome were recruited. Exclusion criteria were psychosis, mental retardation and active substance abuse.
© 2014 S. Karger AG, Basel 0033–3190/14/0836–0377$39.50/0 E-Mail [email protected] www.karger.com/pps
Following written informed consent and prior to the beginning of treatment, participants completed the Emotional Inhibition Scale (EIS) [1] and the Symptom Checklist-90 (SCL-90) [8]. The EIS is a 16-item questionnaire including 4 subscales: ‘verbal inhibition’, ‘disguise of feelings’, ‘timidity’, and ‘self-control’. Evidence of its psychometric properties has been reported elsewhere [1]. Subjects also underwent the Structured Clinical Interview for Personality Disorders (SCID-P) [9]. Two-tailed partial correlations were performed to assess the relationship between the number of SCID-P avoidant, dependent, obsessive-compulsive and borderline traits and EIS total and subscale scores, while controlling for the SCL-90 global severity index (GSI). The GSI was included as a covariate to rule out the possibility that any observed relationship was just the result of heightened levels of psychopathology. To avoid type I errors given the number of correlations calculated, the p level was set at 0.01. The mean age of the sample was 36.8 years (±9.7; range 19–66); 76 subjects (55.1%) were women and 62 (44.9%) were men. Table 1 shows the relationships between EIS scores and SCID-P traits. For exploratory purposes we correlated the EIS subscales with the depression, anxiety and hostility subscales of the SCL-90. These revealed no significant correlations at the 0.01 level. Although the correlational nature of this study does not allow any conclusions regarding causality, our results may offer some implications for a better understanding of the clinical manifestations of PDs and the refinement of their treatment. Avoidant traits were associated with EI. Avoidant traits may be a significant risk factor for the development of EI, but it cannot be excluded that EI contributes to the development of avoidant traits. This issue cannot be solved here given the correlational nature of this study and is a matter for future research. Given the expectation that others will reject or criticize
Giancarlo Dimaggio Centro di Terapia Metacognitiva Interpersonale Piazza dei Martiri di Belfiore, 4 IT–00195 Roma (Italy) E-Mail gdimaje @ libero.it
them, people with avoidant traits are afraid to disclose the nature of their feelings and try to suppress signs that would reveal their drives. The reduction of EI through specific psychotherapeutic strategies may assist people with avoidant traits to disclose painful feelings and develop relationships with others that support healthy functioning. Dependent traits were marginally associated with EIS ‘timidity’. People with high levels on this subscale find it difficult to speak up for their rights and let others take advantage of them. Dependent traits could prevent subjects from developing assertive skills. This finding seems to support the inclusion of assertive training among the therapeutic ingredients in the treatment of dependent personality. No dimension of EI, as assessed by the EIS, was found to be significantly associated with obsessive-compulsive traits. A previous study on early maladaptive schemas found obsessive-compulsive PD unrelated to the cognitive schema of EI [10]. Different underlying mechanisms could explain the seemingly similar tendency to suppress emotional expression in subjects with cluster C PDs. Avoidant and dependent traits may be associated with conscious inhibition of perceived emotional states, as operationalized by the EIS, because of fear of being abandoned or losing support. A thorough understanding of the relationship between EI and personality traits may help in identifying similarities and boundaries between different PDs. The negative correlation between EIS ‘selfcontrol’ and borderline traits is consistent with the impulsive tendencies of patients with borderline PD [9]. Of note, the magnitude of the correlations was small, except the association between avoidant traits and EI. Future studies including people with fully developed cluster C diagnoses excluding cooccurrence with other PDs may find more robust associations than just exploring the correlates of traits. Additionally, one limitation of the use of the SCL-90 GSI is that it might tap into a response style and not merely symptom severity. Our findings point to further studies aimed at assessing which factors (e.g. anxiety, depressive symptoms, dysfunctional interpersonal patterns) may mediate or moderate the association between EI and PD. Furthermore, the observed relationship between EI and
378
Psychother Psychosom 2014;83:377–378 DOI: 10.1159/000365110
avoidant PD suggests that EI may be considered a treatment target. Future studies should examine whether the refinement of psychotherapeutic strategies for the components of EI improve the outcome for PDs, and in particular for avoidant PD. Disclosure Statement The authors have no conflicts of interest to declare.
References 1 Grandi S, Sirri L, Wise TN, Tossani E, Fava GA: Kellner’s Emotional Inhibition Scale: a clinimetric approach to alexithymia research. Psychother Psychosom 2011;80:335–344. 2 Pennebaker JW, Kiecolt-Glaser JK, Glaser R: Disclosure of traumas and immune function: health implications for psychotherapy. J Consult Clin Psychol 1988;56:239–245. 3 Dimaggio G, Salvatore G, Fiore D, Carcione A, Nicolò G, Semerari A: General principles for treating personality disorder with a prominent inhibitedness trait: towards an operationalizing integrated technique. J Pers Disord 2012;26:63–83. 4 Spinhoven P, Bamelis L, Molendijk M, Haringsma R, Arntz A: Reduced specificity of autobiographical memory in cluster C personality disorders and the role of depression, worry, and experiential avoidance. J Abnorm Psychol 2009;118:520–530. 5 Farmer RF, Nelson-Gray RO: Anxiety, impulsivity, and the anxious-fearful and erratic-dramatic personality disorders. J Res Pers 1995;29:189–207. 6 Pastor MC, Ross SR, Segarra P, Montañés S, Poy R, Moltó J: Behavioral inhibition and activation dimensions: relationship to MMPI-2 indices of personality disorder. Pers Individ Dif 2007;42:235–245. 7 Livesley WJ, Jang KL, Vernon PA: Phenotypic and genetic structure of traits delineating personality disorder. Arch Gen Psychiatry 1998;55:941–948. 8 Derogatis LR: SCL-90-R: Administration, Scoring, and Procedures Manual, ed 3. Minneapolis, National Computer Systems, 1994. 9 First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS: Structured Clinical Interview for DSM-IV Axis II Personality Disorders, (SCID-II). Washington, American Psychiatric Press, 1997. 10 Jovev M, Jackson HJ: Early maladaptive schemas in personality disordered individuals. J Pers Disord 2004;18:467–478.
Popolo /Lysaker /Salvatore /Montano / Buonocore /Sirri /Imbimbo /Dimaggio
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
