Experiential avoidance (EA) describes how a person cannot remain in contact with particularly unpleasant internal experiences (e.g., thoughts, emotions, bodily sensations) and takes measures to avoid or escape the experiences altogether. Psychiatric literature has linked EA to a range of disorders, particularly generalized anxiety disorder and social anxiety disorder.
Now, Mary C. Zanarini, EdD, director of the Laboratory for the Study of Adult Development at McLean Hospital, and colleagues have completed one of the few studies of the relationship between EA and borderline personality disorder. In Borderline Personality Disorder and Emotion Dysregulation, they show that EA is a serious problem for many patients with BPD, particularly those who have not recovered.
Methods
The analysis was part of the McLean Study of Adult Development, a longitudinal study of the course of BPD. Inpatients at McLean Hospital, ages 18 to 35, were enrolled from June 1992 to December 1995, and the last follow-up interview was completed in December 2018.
Baseline assessments included the Structured Clinical Interview for DSM-III-R Axis I Disorders, the Revised Diagnostic Interview for Borderlines (DIB-R), and the Diagnostic Interview for DSM-III-R Personality Disorders. At each of the 12 follow-up waves, separated by 24 months, the same diagnostic battery was administered blind to previous diagnoses.
Other assessments included:
- The Revised Childhood Experience Questionnaire, administered at baseline
- The Abuse History Interview, administered at baseline and each follow-up
- The NEO Personality Five-Factor Inventory, administered at baseline and each follow-up
At the study’s 24-year follow-up, 248 participants completed the Overall Anxiety Severity and Impairment Scale (OASIS). This five-item self-report measure assesses the severity of anxiety and the degree to which anxiety interfered with social and vocational functioning over the previous week.
BPD vs. Other Personality Disorders
Of the study participants who completed the OASIS, 198 had BPD and 50 had other personality disorders. The total score was significantly higher for those with BPD (7.77 vs. 3.86; P<0.001).
There were significant differences between the groups on all OASIS measures. Participants with BPD were more likely to feel anxious, have more severe anxiety, and avoid situations, places, objects, or activities due to anxiety. Their anxiety also interfered significantly more with work, school, home life, social life, and relationships.
Recovered vs. Non-Recovered Patients With BPD
Recovery in the McLean study was defined as a two-year period in which neither the DIB-R nor the DSM criteria for BPD were met, the participant had at least one emotionally sustaining relationship with a close friend or life partner/spouse, and the participant was able to work or go to school consistently, competently, and on a full-time basis (which included being an unpaid caregiver in the home or elsewhere).
The 119 non-recovered participants with BPD had a significantly higher total OASIS score than the 79 recovered individuals (9.59 vs. 5.03; P<0.001). They were more likely to experience anxiety, have severe anxiety, avoid situations, places, objects, or activities due to anxiety, and have functional impairment due to anxiety.
Predictors of EA
In multivariate analysis, significant predictors of the level of EA were:
- Childhood sexual abuse—coefficient, 0.47 (P=0.005)
- Lower levels of extraversion—coefficient, −0.17 (P=0.001)
Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT), which focuses on decreasing avoidance, is commonly used for the treatment of disorders high in EA, such as panic disorder. When treating individuals with BPD, it could be beneficial to use ACT or incorporate aspects of ACT that target EA into existing evidence-based treatments for BPD, such as dialectical behavioral therapy or mentalization-based treatment.
