Borderline Personality Features and Harmful Dysregulated Behavior:

The Mediational Effect of Mindfulness

Peggilee Wupperman,1,2 Melissa Fickling,3 David H. Klemanski,4
Matthias Berking,5 and Jeannie B. Whitman6
1
John Jay College/City University of New York
2
Yale University School of Medicine
3
University of North Carolina at Greensboro
4
Yale University Department of Psychology
5
University of Marburg, Germany,
6
University of Texas Southwestern Medical Center

Objectives: The current preliminary study investigated whether deficits in mindfulness (awareness,
attentiveness, and acceptance of the present experience) may underlie the relationship of borderline
personality disorder (BPD) features to self-injury and overall acts of harmful dysregulated behavior.
Method: Nonparametric bootstrapping procedures were used to examine theoretical relationships
among variables in a psychiatric sample of adults (N = 70). Participants were asked to imagine them-
selves in distress-inducing situations and then write what they would actually do to decrease distress
in such situations. Results: As hypothesized, mindfulness statistically mediated the relationship
of BPD features to reported acts of (a) self-injury and (b) overall harmful dysregulated behaviors.
Conclusions: Difficulties in the ability to be aware, attentive, and accepting of ongoing experience
may play a role in the relationship of BPD features to harmful dysregulated behaviors. Future research
should clarify potential reciprocal effects between BPD features and mindfulness with prospective,
multioccasion designs.  C 2013 Wiley Periodicals, Inc. J. Clin. Psychol. 69:903911, 2013.

Keywords: mindfulness; dysregulation; borderline personality; self-injury; impulsivity; substance

Borderline personality disorder (BPD) is characterized by pervasive instability in emotions,

interpersonal relationships, and identity, as well as severe and harmful dysregulated behaviors
(American Psychiatric Association, 2000). BPD features are associated with suicide attempts,
nonsuicidal self-injury, substance abuse, physical aggression, disordered eating, and a host of
other dysregulated behaviors that can cause harm to the individual and the individuals fam-
ily (American Psychiatric Association, 2000; Tragesser et al., 2010). These behaviors also have
widespread societal costs, including chronic unemployment, auto accidents, frequent hospital-
ization, and increased utilization of overall healthcare resources (e.g., Linehan & Heard, 1999;
Paris, 1993; Zanarini, Frankenburg, Hennen, Reich, & Silk 2005). Of note is that much of
the healthcare utilization results from the high rates of deliberate self-injury (i.e., nonsuicidal
self-injury or suicide attempts). Among individuals who meet criteria for BPD, approximately
60%80% engage in deliberate self-injury and 8%-10% die by suicide (American Psychiatric
Association, 2000; Pompili, Girardi, Ruberto, & Tatarelli, 2005).
Despite extensive research on harmful dysregulated behaviors in BPD, the constructs that
account for these behaviors are not yet fully understood. We propose that BPD-related

We thank the Donaghue Medical Research Foundation and Dr. Colon Ross for providing support. The
authors also thank their skilled team of coders and research assistants, including Alisa Pisciotta, M.A.,
Monique DiNapoli, M.A., Kathryn James, M.A., Karina Koerner, Ph.D., Michal Yehezkal, M.A., Jennifer
Varley, M.A., and Mia Gintoft, M.D.
Please address correspondence to: Peggilee Wupperman, John Jay College/City University of New York,
Psychology Department, Tenth Floor, 524 W 59th St., New York, NY 10019. E-mail: pegwupp@hotmail.com

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 69(9), 903911 (2013) 

C 2013 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21969

904 Journal of Clinical Psychology, September 2013

dysregulation may involve levels of mindfulness (the ability to be aware, attentive, and ac-
cepting of internal and external experiences; Kabat-Zinn, 1982). Individuals with BPD features
tend to have deficits in mindfulness (Baer, Smith, & Allen, 2004; Fossati, Feeney, Maffei, &
Borroni, 2011; Wupperman, Neumann, & Axelrod, 2008), and these deficits may play a role
in the dysregulated behaviors characteristic of BPD (e.g., Baer et al., 2004; Wupperman et al.,
2008).

Mindfulness, BPD Features, and Dysregulated Behaviors

BPD is associated with intense negative affect and emotional dyscontrol, to the extent that even
mildly uncomfortable situations may quickly seem distressing and intolerable (e.g., Chapman,
Specht, & Cellucci, 2005; Rosenthal et al., 2008; Stiglmayr, Grathwol, & Bohus, 2001). In a
possible effort to cope with these high levels of affective intensity and dyscontrol, individuals
with BPD tend to avoid unpleasant internal and external experiences, including experiences with
even the potential to become unpleasant (Berking, Neacsiu, Comtois, & Linehan, 2009; Hayes
et al., 1996; Rosenthal, Cheavens, Lejuez, & Lynch, 2005). Such avoidance is consistent with the
inverse relationship of BPD features to mindfulness levels; individuals who display difficulties
being attentive to and aware of current emotions, thoughts, and events (i.e., mindfulness deficits)
are likely to have specific difficulties experiencing emotions, thoughts, and events that have the
possibility of becoming distressing. However, one cannot habituate to a distressing stimulus until
one experiences it, and chronic avoidance often leads to the prolongation and even intensification
of distress (Hayes et al., 1996). Thus, when individuals with intense negative affect and deficits in
mindfulness are unable to avoid, they may feel the need to exert extreme efforts to down-regulate
the experience by any means, increasing the potential for harmful dysregulated behaviors.
Consistently, extensive evidence suggests that difficulty coping with intense affect is one
of the most prominent factors in BPD-related dysregulation, to the extent that dysregulated
behaviors are widely conceptualized as attempts to regulate or avoid intense negative emotions
(see Berking et al., 2009; Chapman et al., 2005; Klonsky, 2007; Wupperman et al., 2008). Given
that self-injury and other dysregulated behaviors often provide short-term relief from the intense
distress that is common in BPD (e.g., Chapman et al., 2005; Klonsky, 2007), these behaviors are
negatively reinforced and have an increased probability of recurring until they may become
automatic responses to potential discomfort of any type.
Mindfulness may disrupt this cycle through a number of means. First, mindfulness fosters
awareness, attention, and acceptance of ongoing experience, thus facilitating emotional process-
ing, distress tolerance, and habituation to intense affect and urges (e.g., Teasdale et al., 2002).
Second, mindfulness fosters decentering, or the ability to step back mentally from automatic
judgments and reactions to become aware of alternate ways of responding (e.g., Bowen et al.,
2009; Teasdale et al., 2002). Therefore, one can become aware of urges to engage in dysregulated
behavior and, instead of automatically acting on those urges, view the dysregulated behavior as
one possible reaction, while also being aware of more-adaptive mechanisms of coping. Third,
mindfulness increases the ability to recognize early signs of escalating negative arousal, thus
allowing individuals to engage in adaptive coping while emotions and urges are more man-
ageable (e.g., Bowen et al., 2009). Finally, increasing evidence indicates that mindfulness is
associated with enhancements in neural pathways involved in behavioral and affect regulation
(e.g., Creswell, Way, Eisenberger, & Lieberman, 2007; Holzel et al., 2011).
Consistently, self-report levels of trait mindfulness are negatively related to a variety of harm-
ful dysregulated behaviors, from self-injury to aggression to disordered eating (e.g., Brown &
Ryan, 2003; Lavender, Jardin, & Anderson, 2009; Lundh, Karim, & Quilisch, 2007). In addition,
mindfulness training is a component of several therapies that target dysregulated behaviors, in-
cluding dialectical behavior therapy, an empirically supported BPD treatment (Linehan et al.,
2006), as well as transdiagnostic therapies that focus on dysregulated behaviors (e.g., Bowen
et al., 2009; Wupperman et al., 2012). Thus, mindfulness might be a protective factor against
the harmful dysregulated behaviors that are often associated with BPD features. Mindfulness
may allow an individual to experience intense and dysregulated emotions without resorting to
the dysregulated behaviors that, paradoxically, often result in increased long-term distress and
 BPD and Mindfulness 905

negative environmental consequences. Instead, mindfulness may allow the individual to utilize
more-adaptive mechanisms for coping with intense emotions, which may involve regulating the
emotions or even tolerating the emotions until they naturally diminish.
The aim of this preliminary study was to help clarify whether deficits in mindfulness may play
a role in the relationship of BPD features to self-injury and other harmful dysregulated behaviors.
To this extent, psychiatric inpatients were asked to (a) take a moment to imagine themselves
in distressing situations, and then (b) write what they would actually do to decrease distress
in such situations. Responses were then scored for self-injury and overall harmful dysregulated
acts. Because of the high individual and societal cost of deliberate self-injury in individuals with
BPD features, we first investigated whether mindfulness deficits were involved in the relationship
between BPD features and reported acts of deliberate self-injury. We then investigated whether
mindfulness deficits were involved in the relationship between BPD features and all reported acts
of harmful dysregulated behaviors (including hazardous drinking, aggression, drug use, binge
eating, etc.). More specifically, we hypothesized that (a) mindfulness would partially mediate
the relationship between BPD features and reports of deliberate self-injury, and (b) mindfulness
would partially mediate the relationship between BPD features and reports of all acts of harmful
dysregulated behavior.

Materials and Method

Participants
The current study relied on data from a larger project designed to examine the associations
between mindfulness deficits, BPD features, and related constructs. A previous study from that
project found that mindfulness levels were associated with BPD features even when control-
ling for interpersonal dysfunction, passive and dysregulated emotion-regulation strategies, and
neuroticism, thus providing support for the role of mindfulness deficits in BPD features (Wupper-
man, Neumann, Whitman, & Axelrod, 2009). The analyses for the current study are original and
extend those that were reported in the previous study. Participants were 70 psychiatric inpatients
admitted to the Trauma and Personality Disorders Unit of a psychiatric hospital. Admission cri-
teria included a history of psychological trauma and current severe impairment, such as strong
suicidal ideation and/or behaviors destructive to self or others, as determined by a clinical
interview.
Of note is that psychological trauma was broadly defined by the unit, and patients were
not required to meet criteria for any trauma disorders. The unit excluded patients requiring
immediate substance-use interventions and patients with conditions that would preclude par-
ticipation in psychosocial programming. No inclusion/exclusion criteria were utilized for study
participation other than admission to the unit. Participants included 59 women, 10 men, and one
who did not report gender. Race/ethnicity included 76% non-Hispanic Caucasian, 7% Black,
6% Hispanic, 1% Asian, and 9% other. Average age was 38.30 (standard deviation [SD] =
9.41), and 64% were unemployed.
The institutional review boards of the hospital and related university approved this study.
Participants received a description of the study and provided verbal and written informed
consent before completing the measures described in the Measures section, as well as additional
measures not utilized in this study.

Measures
Mindfulness. The Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003)
assesses levels of trait mindfulness (i.e., attention to and awareness of emotions, thoughts,
sensations, and situations). Participants specify frequency of experience on a 6-point scale;
items include I could be experiencing some emotion and not be conscious of it until sometime
later. The MAAS has displayed high internal consistency (.82.87), convergent validity, and
discriminant validity in a variety of populations (Brown & Ryan, 2003). Internal consistency in
the current study was good (.81).
906 Journal of Clinical Psychology, September 2013

Borderline personality features. The Borderline Features Scale of the Personality As-
sessment InventoryTM (PAI R
-BOR; Morey, 1991) includes 24 items that assess BPD-related
psychopathology. The BPD Scale has shown exceptional internal consistency and clinical, con-
vergent, and discriminant validity in a range of samples (Morey, 1991; Trull, 2001). Internal
consistency in the current sample was acceptable (.75). In the current sample, scores ranged
from 25 to 65. Ninety percent of participants received a score 38, which suggests clinically
significant BPD features (Morey, 1991; Trull, 2001).

Self-injury and overall dysregulated behaviors in efforts to reduce distress. To assess

use of self-injury and overall dysregulated behavior in response to distress, we followed the
lead of earlier studies and utilized an adapted Means-End Problem-Solving Test for emotions
(MEPS-Emo; Kehrer & Linehan, 1996; Linehan et al., 1987; Wupperman et al., 2008). The
MEPS-Emo contains three vignettes that each describes a distressing situation and an ending
(which occurs after an undefined interval) in which the distress is decreased. Participants were
asked to (a) take a moment to imagine themselves in each situation, and then (b) write what they
would actually do to achieve the ending described in each vignette (or, in other words, how they
would calm themselves after becoming distressed). Participants were strongly instructed to write
how they would normally respond in each situation, not how they think they should respond.
Vignettes included partner leaving, friendship difficulties, and overwhelmed by work colleagues.
For example:

You love your partner very much, but you have had many arguments. One day,
after an argument over your partner flirting with someone else, your partner says
the relationship is over and walks out on you. You feel extremely rejected and
hopeless. The story ends with you feeling calmer and more optimistic. You begin
the story where you are feeling rejected and hopeless.

Two scales were utilized to score each vignette: We first coded the number of acts consisting
of self-injury (including cutting, burning, scratching, etc.). We then counted the number of
acts comprising any harmful dysregulated behavior (including substance misuse, binge eating,
aggression, etc.). Scores were then summed to give each participant a total score for self-injury
and a total score for harmful dysregulated behaviors. Internal consistency was fair for self-
injury (.58) and good for dysregulated behavior (.70). Per previous research (Wupperman et al.,
2008; Wupperman et al., 2009), two trained raters scored the MEPS-Emo responses. Interrater
reliability was r = .89 for self-injury acts and r = .85 for dysregulated acts.

Statistical Analyses
Nonparametric bootstrapping procedures were employed to calculate indirect effects using
PROCESS in SPSS, a computational tool for observed variable mediation (c.f. Hayes, 2012).
Bootstrapping is a particularly useful method for testing indirect effects, as it does not impose
assumptions about distribution of the variables or sampling statistics, and it is therefore effective
in providing robust estimates and addressing power limitations (Preacher & Hayes, 2004, 2008).
In testing for statistical mediation, the dependent variable is regressed on the independent
variable and on the mediator; the mediator is also regressed on the independent variable. A
significant indirect effect (a b) indicates partial mediation, and a direct effect (of the independent
variable on the dependent variable; c) not significantly different from zero indicates full statistical
mediation. Bootstrapping procedures involve randomly resampling data with replacement from
the original sample; for this study, data were resampled 10,000 times, generating the same number
of independent estimates of the indirect and direct effects of BPD features on each outcome.
Consistent with guidelines put forth by Preacher and Hayes, assessment of significant indirect
effects was based on evaluation of 95% confidence intervals (CIs) for unstandardized path
coefficients not containing zero within range estimates and an alpha level of .05 (c.f. Preacher &
Hayes, 2004; Hayes, 2009; MacKinnon et al., 2002).
 BPD and Mindfulness 907

Table 1
Descriptive statistics (N = 70)

Total sample

Measures Mean SD Internal consistency

Borderline features (PAI-BOR) 46.84 8.55 .75

Mindfulness (MAAS) 39.60 9.73 .81
Acts of self-injury (MEPS-Emo-I) 0.72 0.90 .58
Acts of harmful dysregulated behavior (MEPS-Emo-D) 1.99 1.84 .70

Note. PAI-BOR = Borderline Features Scale of the Personality Assessment Inventory; MAAS = Mindful
Attention Awareness Scale; MEPS-Emo = Means-End Problem-Solving Test-Emotions; SD = standard
deviation.

Table 2
Summary of Mediation Analysis Path Coefficients and Standard Errors (in Parentheses)

Independent Mediating Dependent Effect of Effect of Direct Indirect Total

variable variable variable IV on M on effects effect effects BC CI
(IV) (M) (DV) M (a) DV (b) (c) (a b) (c) 95%

1. BPD Features Mindfulness Acts of 0.51*** 0.03* 0.02 0.01 0.03** >.01-.03
self-injury (0.12) (0.01) (0.01) (0.01) (0.01)
2. BPD Mindfulness Acts of harmful 0.51*** 0.07** 0.04 0.03 0.07** .01-.08
Features dysregulated (0.12) (0.04) (0.03) (0.02) (0.02)
behavior

Note. BC CI = Bias Corrected Confidence Interval (Lower and upper limits presented for indirect effect);
BPD = borderline personality disorder.
* p < .05. ** p < .01. *** p < .001.

Results
Descriptive statistics are presented in Table 1. Skew for all variables was generally acceptable
(0.29 to 1.21) considering the nature of the sample. Mindfulness was significantly and negatively
correlated with BPD features (r = .45, p < .001), acts of self-injury (r = .35, p <.01), and
acts of harmful dysregulated behavior (r = .44, p < .01). BPD features showed a significant
positive relationship to acts of deliberate self-injury (r = .32, p < .01) and dysregulated behavior
(r = .34, p < .01). Measures demonstrated adequate-to-good internal consistency.
Results of the bootstrapping analyses are presented in Table 2. These analyses confirmed that
BPD features were positively and significantly associated with (a) acts of self-injury and (b) acts of
harmful dysregulated behavior. Further, BPD features were inversely and significantly associated
with mindfulness (a weight), and mindfulness was inversely and significantly associated with acts
of self-injury and acts of dysregulated behavior (b weights). Finally, both indirect effects (a b)
were significant (i.e., the upper and lower limits of the confidence intervals did not contain zero),
and both direct effects (c weights) were not. These findings indicate that the associations of BPD
features to acts of self-injury and acts of harmful behavior were both mediated by deficits in
mindfulness. Effect sizes were not calculated for nonparametric bootstrapping analyses because
point estimates of indirect effects are scaled relative to the predictor and outcome variable, but
not for the mediator (c.f. Hayes, 2009).

Discussion
Although the relationship of BPD features to harmful dysregulated behavior is widely acknowl-
edged (e.g., American Psychological Association, 2000; Chapman et al., 2005), the mechanisms
that account for this relationship are not yet understood. Thus, the aim of this study was to
help clarify whether deficits in mindfulness may explain how BPD features lead to self-injury
908 Journal of Clinical Psychology, September 2013

and other harmful dysregulated behaviors. For this purpose, we assessed whether mindfulness
statistically mediated the relationship of BPD features to reported acts of self-injury and acts of
overall dysregulated behavior. Consistent with hypotheses, results provide evidence for a statisti-
cal mediation. Additional studies are needed to confirm that this statistical mediation expresses
actual (i.e., causal) mediation (Kraemer, Wilson, Fairburn, & Agras, 2002); however, these pre-
liminary results suggest that the link between severity of BPD features and harmful dysregulated
behavior may involve difficulties experiencing current emotions, thoughts, and sensations (i.e.,
mindfulness deficits).
These results are consistent with the theoretical explanation of the effects of mindfulness. An
individuals difficulty experiencing/tolerating present emotions, thoughts, and sensations would
likely leave that individual less able to use adaptive coping strategies when faced with situations
that involve negative affect (as one cannot choose an adaptive strategy for coping with affect
if one cannot tolerate the experience of the affect being present in the first place). In addition,
as adaptive coping strategies may not decrease the affect as quickly as would dysregulated
behaviors (especially in early abstinence from those behaviors), mindfulness deficits may leave
the individual feeling less able to tolerate residual negative affect and urges even when adaptive
coping is initially attempted. Therefore, individuals with high affect intensity and low levels of
mindfulness may attempt to avoid potentially unpleasant experiences, either in response to the
initial cue or after attempts at coping have not fully alleviated the experience. In other words,
an individual with BPD features and mindfulness deficits may chronically attempt to avoid the
experience of potentially upsetting situations, which may involve the use of harmful dysregulated
behaviors to down-regulate emotions when such situations cant be avoided.
These findings may explain how some individuals with strong BPD features may experience
negative affect without engaging in self-injury or other harmful behaviors. Finally, these find-
ings are also consistent with research showing promising results for mindfulness-focused treat-
ments targeting a variety of dysregulated behaviors, such as alcohol/drug-use disorders (Bowen
et al., 2009), smoking (Brewer et al., 2011), self-injury (Gratz & Gunderson, 2006: Linehan
et al., 2006), and eating-disordered behaviors (Wanden-Berghe, Sanz-Valero, & Wanden-Berghe,
2011), as well as a transdiagnostic treatment for individuals with multiple areas of dysregulated
behavior (such as substance abuse and physical aggression; Wupperman et al., 2012).
Of note is that the relationship of BPD features to mindfulness is likely not stagnant; instead,
BPD features and mindfulness likely have reciprocal effects over time. Thus, deficits in the
ability to experience and tolerate current emotions/thoughts/sensations may lead to increased
BPD features (as proposed in Wupperman et al., 2009), and the intense negative affect and
lability of BPD features may lead to additional difficulties experiencing and tolerating current
emotions/thoughts/sensations (which may lead to increased dysregulated behaviors, as would
be consistent with the current findings). The evaluation of such a model is beyond the scope of
this study.

Limitations
The major limitation of this study is the use of a cross-sectional design, which allows identification
of statistical mediation but does not provide definitive evidence of actual, or causal, mediation.
Cross-sectional studies can test only whether the assumed cause and effect co-occurs, not whether
the assumed cause precedes the assumed effect or whether the association is caused by a third
factor. Thus, findings from the present study provide only preliminary evidence for causal
mediation.
Additionally, this study used self-report measures to assess BPD and scored written responses
to assess reported tendency to engage in acts of self-injury and overall dysregulated behaviors in
response to distress. Although self-report measures are preferable for investigations such as this
on the dimensionality of BPD (Widiger, 1992), the data collected did not allow for characterizing
the participants diagnostically. (However, research indicates that self-report measures are as
valid for assessing BPD pathology as are diagnostic interviews; Hopwood et al., 2008). In
addition, lack of access to patient files precluded us from controlling for covariates such as Axis
I disorders. Finally, the selection of an inpatient sample provides support for mindfulness as a
 BPD and Mindfulness 909

protective factor against harmful dysregulated behavior even in the presence of severe personality
psychopathology; however, the use of this sample also may limit generalizability to less-severe
clinical populations, such as individuals in outpatient treatment.

Future Directions
The current study can only begin to elucidate the complex relations of BPD features, mind-
fulness, and dysregulated behaviors. Longitudinal studies and cross-sectional panel analyses
are needed to investigate whether BPD features and mindfulness may have reciprocal effects:
in other words, whether difficulties tolerating internal and external experiences may lead to
increased BPD features, and the intense negative affect of BPD features may then lead to addi-
tional difficulties tolerating internal and external experiences (which may then lead to increased
behavioral dysregulation).
Future research should focus on evaluating such dynamic models in prospective multioccasion
studies (e.g., Ferrer & Nesselroade, 2003). Future research should also include additional as-
sessment methods, including diagnostic interviews, assessments of actual incidents of self-injury
and dysregulated behaviors, ambulatory monitoring, physiological measures, and/or laboratory
experimental procedures. Studies on the relationship of specific BPD features to mindfulness
and/or dysregulated behaviors would further illuminate the complex mechanisms involved in
dysregulated behavior. Finally, treatment studies are needed to explore the potential role of
mindfulness training as a mechanism in decreasing dysregulated behavior.

Conclusion
The present study adds to the literature by increasing understanding of the potential mechanisms
underlying harmful dysregulated behavior in individuals with BPD features. Results suggest that
deficits in mindfulness may play a role in the relationship of BPD features to self-injury and other
dysregulated behaviors in reaction to distressing events. Thus, this study provides preliminary
support for the role of mindfulness as a potential protective factor against harmful dysregulated
behavior.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.,
text rev.). Washington, DC: Author.
Baer, R. A., Smith, G. T., & Allen, K. B. (2004). Assessment of mindfulness by self-report: The Kentucky
Inventory of Mindfulness Skills. Assessessment, 11(3), 191206.
Baron, R. M., & Kenny, D. A. (1986). The moderatormediator variable distinction in social psycholog-
ical research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social
Psychology, 51(6), 11731182.
Berking, M., Neacsiu, A., Comtois, K. A. & Linehan, M. M. (2009). The impact of experiential avoidance
on the reduction of depression in treatment for borderline personality disorder. Behaviour Research and
Therapy, 47(8), 663670.
Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., . . . Marlatt, G. A. (2009).
Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance
Abuse, 30(4), 295305.
Brewer, J. A., Mallik, S., Babuscio, T. A., Nich, C., Johnson, H. E., Deleone, C. M., & . . . Rounsaville, B.
J. (2011). Mindfulness training for smoking cessation: Results from a randomized controlled trial. Drug
And Alcohol Dependence, 119, 7280.
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological
well-being. Journal of Personality and Social Psychology, 84(4), 822848.
Chapman, A. L., Specht, M. W., & Cellucci, T. (2005). Borderline personality disorder and deliberate self-
harm: Does experiential avoidance play a Role? Suicide and Life-Threatening Behavior, 35(4), 388399.
Creswell, J. D., Way, B. M., Eisenberger, N. I., & Lieberman, M. D. (2007). Neural correlates of dispositional
mindfulness during affect labeling. Psychosomatic Medicine, 69(6), 560565.
910 Journal of Clinical Psychology, September 2013

Ferrer, E., & Nesselroade, J. (2003). Modeling affective processes in dyadic relations via dynamic factor
analysis. Emotion, 3, 344360.
Fossati, A., Feeney, J., Maffei, C., & Borroni, S. (2011). Does mindfulness mediate the association between
attachment dimensions and borderline personality disorder features? A study of Italian non-clinical
adolescents. Attachment & Human Development, 13, 563578.
Gratz, K. L., & Gunderson, J. G. (2006). Preliminary data on an acceptance-based emotion regulation
group intervention for deliberate self-harm among women with borderline personality disorder. Behavior
Therapy, 37, 2535.
Hayes, A. F. (2009). Beyond Baron and Kenny: Statistical mediation analysis in the new millennium.
Communication Monographs, 76, 408420.
Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation, mod-
eration, and conditional process modeling [White paper]. Retrieved from http://www.afhayes.com/
public/process2012.pdf
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance
and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of
Consulting and Clinical Psychology, 64(6), 11521168.

Holzel, B. K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S. M., Gard, T., & Lazar, S. W. (2011).
Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research:
Neuroimaging, 191(1), 3643.
Hopwood, C. J., Morey, L. C., Edelen, M. O., Shea, M. T., Grilo, C. M., Sanislow, C. A., . . . Skodol, A. E.
(2008). A comparison of interview and self-report methods for the assessment of borderline personality
disorder criteria. Psychological Assessment, 20, 8185.
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on
the practice of mindfulness meditation: Theoretical considerations and preliminary results. General
Hospital Psychiatry, 4, 3347.
Kehrer, C. A., & Linehan, M. M. (1996). Interpersonal and emotional problem solving skills and parasuicide
among women with borderline personality disorder. Journal of Personality Disorders, 10(2), 153163.
Klonsky, E. D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology
Review, 27(2), 226239.
Kraemer, H., Wilson, G., Fairburn, C. G., & Agras, W. (2002). Mediators and moderators of treatment
effects in randomized clinical trials. Archives of General Psychiatry, 59(10), 877883.
Lavender, J. M., Jardin, B. F., & Anderson, D. A. (2009). Bulimic symptoms in undergraduate men and
women: Contributions of mindfulness and thought suppression. Eating behaviors, 10(4), 228231.
Linehan, M. M., Camper, P., Chiles, J. A., Strosahl, K., & Shearin, E. (1987). Interpersonal problem solving
and parasuicide. Cognitve Therapy Research, 1, 112.
Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., . . . Lindenboim,
N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy
by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry,
63(7), 757766.
Linehan, M. M., & Heard, H. L. (1999). Borderline personality disorder: Costs, course, and treatment
outcomes. In N. E. Miller & K. M. Magruder (Eds.), Cost-effectiveness of psychotherapy: A guide for
practitioners, researchers, and policymakers (pp. 291305). New York, NY: Oxford University Press.
Lundh, L., Karim, J., & Quilisch, E. (2007). Deliberate self-harm in 15-year-old adolescents: A pilot study
with a modified version of the Deliberate Self-Harm Inventory. Scandinavian Journal of Psychology,
48(1), 3341.
MacKinnon D. P., Lockwood, C. M., Hoffman, J. M., West, S. G., & Sheets, V. (2002). A comparison of
methods to test mediation and other intervening variable effects. Psychological Method, 7, 83104.
Morey, L. (1991). Personality Assessment Inventory: Professional Manual. Odessa, FL: Psychological
Assessment Resources.
Muthen, L. K., & Muthen, B. O. (19982010). Mplus users guide (6th ed.). Los Angeles, CA: Muthen &
Muthen.
Paris, J. (1993). The treatment of borderline personality disorder in light of the research on its long term
outcome. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 38(suppl 1), 28
34.
Pompili, M., Girardi, P., Ruberto, A., & Tatarelli, R. (2005). Suicide in borderline personality disorder: A
meta-analysis. Nordic Journal of Psychiatry, 59(5), 319324.
 BPD and Mindfulness 911

Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect effects in simple
mediation models. Behavior Research Methods, Instruments, and Computers, 36, 717731.
Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing
indirect effects in multiple mediator models. Behavior Research Methods, 40, 879891.
Rosenthal, M., Cheavens, J. S., Lejuez, C. W., & Lynch, T. R. (2005). Thought suppression mediates the
relationship between negative affect and borderline personality disorder symptoms. Behaviour Research
And Therapy, 43, 11731185
Rosenthal, M., Gratz, K. L., Kosson, D. S., Cheavens, J. S., Lejuez, C. W., & Lynch, T. R. (2008). Borderline
personality disorder and emotional responding: A review of the research literature. Clinical Psychology
Review, 28, 7591.
Stiglmayr, C., Grathwol, T., & Bohus, M. (2001). States of aversive tension in patients with borderline
personality disorder: A controlled field study. In J. J. Fahrenberg & M. M. Myrtek (Eds.), Progress in
ambulatory assessment: Computer-assisted psychological and psychophysiological methods in monitor-
ing and field studies (pp. 135141).
Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z. V. (2002). Metacognitive
awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical
Psychology, 70(2), 275287.
Tragesser, S. L., Solhan, M., Brown, W. C., Tomko, R. L., Bagge, C., & Trull, T. J. (2010). Longitudinal
associations in borderline personality disorder features: Diagnostic Interview for BorderlinesRevised
scores over time. Journal of Personality Disorders, 24, 377391.
Trull, T. J. (2001) Structural relations between borderline personality disorder features and putative etiolog-
ical correlates. Journal of Abnormal Psychoogy, 110, 471 481.
Wanden-Berghe, R., Sanz-Valero, J., & Wanden-Berghe, C. (2011). The application of mindfulness to eating
disorders treatment: A systematic review. Eating Disorders: The Journal of Treatment & Prevention, 19,
3448.
Widiger, T. A. (1992). Categorical versus dimensional classification: Implications from and for research.
Journal of Personality Disorders, 6, 287300.
Wupperman, P., Marlatt, G. A., Cunningham, A., Bowen, S., Berking, M., Mulvihill-Rivera, N., & Easton,
C. E. (2012). Mindfulness and modification therapy for behavioral dysregulation: Results from a pilot
study targeting alcohol use and aggression in women. Journal of Clinical Psychology, 68(1), 5066.
Wupperman, P., Neumann, C. S., & Axelrod, S. R. (2008). Do deficits in mindfulness underlie borderline
personality features and core difficulties. Journal of Personality Disorders, 22(5), 466482.
Wupperman, P., Neumann, C. S., Whitman, J. B., & Axelrod, S. R. (2009). The role of mindfulness in
borderline personality disorder features. Journal of Nervous and Mental Disease, 197, 766772.
Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, B., & Silk, K. R. (2005). The McLean Study of
Adult Development (MSAD): Overview and implications of the first six years of prospective follow-up.
Journal of Personality Disorders, 19, 505523.