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Pregnancy

Childbirth

BMC

Pregnancy

Childbirth

Published

online

Jul

doi

PMCID

Vaginal

breech

delivery

results

of

a

prospective

registration

study

Ingvild

Vistad

Milada

Cvancarova

Berit

L

Hustad

and

Tore

Henriksen

Author

information

Article

notes

Copyright

and

License

information

This

article

has

been

cited

by

other

articles

in

PMC

Go

to

Abstract

Background

Most

countries

recommend

planned

cesarean

section

in

breech

deliveries

which

is

considered

safer

than

vaginal

delivery

As

one

of

few

countries

in

the

western

world

Norway

has

continued

to

practice

planned

vaginal

delivery

in

selected

women

The

aim

of

this

study

is

to

evaluate

prospectively

registered

neonatal

and

maternal

outcomes

in

term

singleton

breech

deliveries

in

a

Norwegian

hospital

during

a

ten

years

period

We

aim

to

compare

maternal

and

neonatal

outcomes

in

term

breech

pregnancies

subjected

either

to

planned

vaginal

or

elective

cesarean

section

Methods

A

prospective

registration

study

including

women

with

term

breech

deliveries

weeks

consecutively

registered

at

Sorlandet

Hospital

Kristiansand

between

and

Fetal

and

maternal

outcomes

were

compared

according

to

delivery

method

planned

vaginal

delivery

versus

planned

cesarean

section

Results

Of

women

elective

cesarean

section

was

planned

in

cases

and

vaginal

delivery

was

planned

in

cases

Acute

cesarean

section

was

performed

in

of

the

planned

vaginal

deliveries

There

were

no

neonatal

deaths

Two

cases

of

serious

neonatal

morbidity

were

reported

in

the

planned

vaginal

group

One

infant

had

seizures

brachial

plexus

injury

and

cephalhematoma

The

other

infant

had

Apgar

Twentynine

in

the

planned

vaginal

group

and

eight

in

the

planned

cesarean

section

group

p

were

transferred

to

the

neonatal

intensive

care

unit

However

only

one

infant

was

admitted

Conclusions

Strict

guidelines

were

followed

in

all

cases

There

were

no

neonatal

deaths

Two

infants

had

serious

neonatal

morbidity

in

the

planned

vaginal

group

without

longterm

sequelae

Go

to

Background

In

the

results

of

a

randomized

multicenter

trial

the

Term

Breech

Trial

TBT

were

published

in

the

Lancet

women

were

included

in

the

study

and

of

the

women

assigned

to

planned

vaginal

delivery

delivered

by

this

method

The

trial

reported

significantly

lower

perinatal

mortality

neonatal

mortality

or

serious

neonatal

morbidity

in

the

planned

cesarean

section

arm

versus

in

the

planned

vaginal

delivery

arm

The

TBT

has

had

a

major

impact

on

clinical

practice

and

most

countries

now

recommend

planned

cesarean

section

in

breech

births

Later

several

methodological

aspects

of

the

study

have

been

questioned

Despite

this

planned

cesarean

section

is

considered

as

the

safest

and

therefore

the

most

widely

used

delivery

method

according

to

several

European

publications

As

a

response

to

the

TBT

a

Norwegian

expert

group

in

reviewed

published

international

literature

on

breech

births

and

obtained

information

on

perinatal

morbidity

and

mortality

in

term

breech

infants

in

Norway

Their

results

showed

a

lower

perinatal

morbidity

among

infants

born

vaginally

in

breech

presentation

compared

to

both

study

groups

of

the

TBT

The

mortality

rate

was

when

corrected

for

lethal

malformations

and

after

the

additional

correction

for

death

before

admission

to

the

maternity

clinic

This

could

be

explained

by

the

close

fetal

monitoring

national

procedures

and

sufficient

skills

of

obstetric

staff

combined

with

high

quality

neonatal

service

in

contrast

to

many

of

the

participating

clinics

in

the

TBT

As

a

result

Norwegian

delivery

units

have

continued

a

practice

with

vaginal

delivery

provided

that

strict

national

guidelines

are

followed

As

one

of

few

countries

in

the

western

world

which

has

continued

to

practice

planned

vaginal

delivery

in

selected

women

quality

control

of

own

practice

is

fundamental

and

sharing

current

experience

with

vaginal

breech

deliveries

has

strongly

been

encouraged

The

purpose

of

this

study

is

to

evaluate

prospectively

registered

neonatal

and

maternal

outcomes

in

term

singleton

breech

deliveries

in

a

Norwegian

hospital

ten

years

after

TBT

We

aim

to

compare

outcomes

in

term

breech

infants

after

planned

vaginal

delivery

versus

after

elective

cesarean

section

Go

to

Methods

Data

collection

Data

on

breech

deliveries

at

our

hospital

has

been

prospectively

collected

in

a

comprehensive

breech

database

since

to

the

present

variables

listed

below

Maternal

delivery

data

as

well

as

neonatal

mortality

and

morbidity

data

are

registered

in

the

data

base

Information

on

maternal

complications

was

extracted

from

medical

charts

and

the

Partus

database

in

retrospect

Medical

charts

were

also

reviewed

for

all

neonates

transferred

to

the

neonatal

intensive

care

unit

NICU

in

order

to

verify

and

validate

information

All

women

with

a

singleton

term

gestation

weeks

breech

presentation

between

and

were

included

Exclusion

criteria

were

preterm

Mode

of

delivery

Breech

deliveries

were

classified

as

planned

vaginal

breech

deliveries

if

the

woman

delivered

vaginally

or

by

acute

cesarean

section

after

a

previous

decision

of

vaginal

delivery

whether

the

decision

was

taken

before

labor

or

after

a

pelvimetry

in

early

labor

Mode

of

planned

delivery

was

recorded

prospectively

in

the

medical

charts

Women

with

breech

presentation

were

selected

to

vaginal

delivery

according

to

Norwegian

guidelines

see

below

After

spontaneous

onset

of

labor

continuous

electronic

fetal

monitoring

was

conducted

in

all

cases

with

known

breech

presentation

In

ST

analyses

of

the

fetal

electrocardiogram

STAN

were

introduced

in

breech

deliveries

After

spontaneous

progress

to

umbilical

level

the

arms

and

the

aftercoming

head

were

actively

delivered

by

the

Lövsets

and

the

VeitSmellieMoriceau

maneuvers

respectively

Norwegian

national

guidelines

for

vaginal

delivery

of

breech

infants

Gestational

age

weeks

Estimated

birth

weight

g

and

g

individual

assessment

between

g

Pelvimetry

xray

was

optionally

performed

in

nulliparous

women

in

women

with

previous

complicated

vaginal

birth

or

previous

birth

of

infant

g

Sagittal

inlet

diameter

more

than

cm

and

sum

of

pelvic

outlet

diameter

more

than

cm

were

accepted

measures

for

vaginal

delivery

Frank

breech

or

complete

breech

presentation

No

serious

obstetrical

complications

or

serious

maternal

diseases

Adequate

institution

size

preferably

more

than

births

a

year

Mode

of

delivery

and

delivery

Neonatal

outcome

factors

Variables

recorded

in

the

breech

database

were

Apgar

score

and

at

minutes

admission

to

NICU

days

brachial

plexus

injury

cephalhematoma

bone

fracture

respiratory

distress

syndrome

mechanical

ventilation

treatment

continuous

positive

airway

pressure

CPAP

treatment

and

facial

palsy

Gestational

length

was

consistently

based

on

ultrasound

examination

at

weeks

or

if

not

available

the

last

menstrual

period

Small

for

gestational

age

SGA

was

defined

as

having

a

birth

weight

lower

than

the

percentile

calculated

for

the

normal

population

based

on

data

from

Norwegian

Birth

Registry

Maternal

outcome

factors

Maternal

age

parity

para

para

gestational

length

birth

weight

xray

pelvimetry

and

indication

for

mode

of

delivery

were

extracted

from

the

breech

database

Maternal

complications

were

not

originally

registered

and

were

extracted

from

medical

charts

and

the

Partus

database

in

retrospect

These

variables

include

episiotomy

anal

sphincter

rupture

blood

loss

dichotomized

to

or

ml

need

for

blood

transfusion

deep

venous

thrombosis

postoperative

hematoma

wound

infection

requiring

antibiotics

endomyometritis

and

febrile

illness

day

The

primary

outcome

measure

was

neonatal

mortality

or

serious

perinatal

morbidity

similar

to

the

criteria

of

the

TBT

Admission

to

NICU

days

cephalohematoma

bone

fracture

respiratory

distress

syndrome

mechanical

ventilation

treatment

continuous

positive

airway

pressure

CPAP

treatment

Apgar

after

minutes

Statistics

Data

were

described

with

proportions

for

categorical

variables

and

with

median

and

ranges

for

continuous

variables

Crude

associations

between

categorical

data

were

assessed

with

chisquare

tests

and

ttests

for

continuous

variables

Nonparametric

tests

were

applied

when

appropriate

The

associations

between

categorical

variables

were

quantified

as

odds

ratios

ORs

with

confidence

intervals

CI

Pvalues

were

considered

statistically

significant

Data

were

analysed

using

the

Statistical

Package

for

Social

Sciences

SPSS

version

Ethics

The

study

was

considered

as

quality

assurance

by

the

regional

Committee

for

Ethics

in

Medical

Research

Region

South

D

and

did

not

require

approval

or

written

consent

The

Norwegian

data

inspectorate

approved

the

study

Go

to

Results

In

the

period

from

to

of

singleton

term

pregnancies

were

breech

presentations

at

Sorlandet

Hospital

Kristiansand

Figure

Three

cases

were

excluded

due

to

known

fetal

anomaly

Of

the

remaining

women

elective

caesarean

section

was

planned

in

cases

whereas

vaginal

delivery

was

planned

in

cases

The

guidelines

were

followed

in

all

cases

We

went

through

the

medical

charts

for

infants

who

were

transferred

to

the

NICU

after

birth

with

a

median

followup

time

of

years

range

years

One

infant

was

diagnosed

with

Downs

syndrome

post

partum

and

one

with

autism

at

two

years

age

These

two

were

not

excluded

from

the

analyses

Acute

caesarean

section

was

performed

in

Figure

Study

flow

chart

Table

reports

maternal

and

obstetric

characteristics

for

the

planned

vaginal

and

caesarean

section

delivery

groups

In

Table

fetal

outcomes

for

the

two

groups

are

reported

Thirteen

percent

were

SGA

infants

with

infants

in

the

planned

vaginal

group

Of

these

a

minority

were

transferred

to

the

NICU

N

Cord

blood

was

sampled

in

cases

in

the

planned

vaginal

group

and

in

the

planned

cesarean

section

group

Acidemia

pH

was

reported

in

cases

in

the

planned

vaginal

group

and

in

the

planned

cesarean

section

group

Two

infants

in

the

planned

vaginal

group

had

a

cord

blood

base

deficit

of

at

least

Seven

infants

in

the

planned

vaginal

group

Table

Maternal

and

obstetric

outcomes

in

the

planned

cesarean

and

planned

vaginal

delivery

groups

Table

Fetal

outcomes

in

the

planned

cesarean

and

planned

vaginal

delivery

groups

In

the

planned

vaginal

delivery

group

the

number

of

successful

vaginal

deliveries

was

higher

among

multiparous

versus

nulliparous

women

vs

p

infants

had

birthweight

g

Of

these

vaginal

delivery

was

planned

in

but

only

infants

were

delivered

by

this

method

weight

range

g

g

had

Apgar

score

after

five

minutes

but

were

transferred

to

NICU

Fifteen

percent

of

the

women

had

an

undiagnosed

breech

presentation

at

birth

and

of

these

women

delivered

vaginally

Of

those

with

vaginal

delivery

an

episiotomy

was

applied

in

Of

the

maternal

postoperative

complications

analyzed

mean

blood

loss

was

the

only

variable

that

was

significantly

higher

in

the

cesarean

section

group

versus

in

the

vaginal

delivery

group

ml

SD

ml

versus

ml

SD

ml

p

Four

women

had

blood

loss

ml

in

the

planned

vaginal

group

compared

to

five

in

the

planned

cesarean

section

group

Table

reports

management

during

labor

and

delivery

for

vaginal

births

Table

Management

of

labor

and

delivery

in

vaginal

births

Go

to

Discussion

In

our

prospective

single

hospital

based

study

planned

vaginal

delivery

of

term

breech

infants

was

associated

with

low

perinatal

morbidity

There

were

no

neonatal

deaths

among

the

breech

babies

in

this

period

Statistically

significantly

more

infants

in

the

planned

vaginal

delivery

group

had

an

Apgar

score

and

were

transferred

to

the

NICU

However

only

one

infant

was

admitted

for

more

than

four

days

Cord

blood

was

only

sampled

in

of

planned

cesarean

section

cases

and

of

planned

vaginal

cases

and

can

therefore

not

be

analyzed

According

to

followup

data

of

the

infants

including

the

Most

authors

conclude

that

cesarean

section

is

associated

with

increased

short

term

maternal

morbidity

However

in

the

present

study

we

found

no

statistical

significant

differences

between

the

groups

except

for

higher

blood

loss

in

the

surgery

group

which

was

of

no

clinical

significance

The

long

term

effects

of

cesarean

section

on

the

risk

of

pregnancy

and

delivery

complications

are

well

documented

These

include

placenta

previa

and

accrete

preterm

delivery

and

pre

and

post

partum

bleeding

which

may

involve

a

risk

for

both

mother

and

child

Most

studies

of

term

breech

deliveries

are

retrospective

and

based

on

registry

data

which

make

comparisons

difficult

because

of

lack

of

antenatal

and

postnatal

information

Our

study

is

in

terms

of

design

comparable

to

a

large

prospective

observation

study

from

FranceBelgium

that

included

women

According

to

that

study

vaginal

delivery

of

breech

infants

remains

standard

practice

in

France

The

proportion

of

planned

vaginal

deliveries

was

in

and

decreased

to

in

the

study

period

In

our

study

vaginal

delivery

was

planned

in

of

breech

births

throughout

the

study

period

varying

from

in

to

in

In

the

study

by

Goffinet

et

al

in

the

planned

vaginal

group

were

transferred

to

the

NICU

versus

in

our

study

However

in

our

study

only

one

of

infants

was

admitted

at

the

NICU

for

more

than

days

compared

to

of

the

infants

in

the

FrenchBelgian

study

The

main

reason

is

probably

variations

in

routines

including

a

low

threshold

for

transfer

to

the

NICU

at

our

hospital

reflected

by

the

short

admission

time

Cultural

and

traditional

differences

between

the

countries

may

also

explain

variations

in

management

of

delivery

In

the

FrenchBelgium

study

duration

of

labor

first

stage

was

In

contrary

to

the

findings

of

the

TBT

and

several

retrospective

studies

we

found

no

excess

risk

for

neonatal

mortality

or

serious

morbidity

in

the

planned

vaginal

delivery

group

versus

in

the

planned

cesarean

section

group

As

the

rate

of

vaginally

delivered

breech

infants

is

much

higher

at

our

institution

compared

to

other

studies

comparisons

are

difficult

to

make

Today

approximately

of

breeches

are

delivered

vaginally

in

the

Netherlands

compared

to

before

the

TBT

The

numbers

are

even

lower

in

Scotland

Ireland

and

Denmark

today

versus

before

the

TBT

There

is

a

risk

that

reduction

in

vaginal

breech

deliveries

may

lead

to

less

skilled

obstetricians

and

less

favorable

results

in

situations

where

vaginal

delivery

is

unavoidable

such

as

undiagnosed

breech

in

advanced

labor

or

delivery

of

second

twin

In

the

prospective

FrenchBelgian

study

of

the

breech

deliveries

went

vaginally

and

the

study

included

only

one

neonatal

death

of

a

nonmalformed

infant

in

the

cesarean

section

group

among

term

breech

deliveries

Furthermore

except

for

a

Apgar

score

less

than

in

a

total

of

five

infants

no

difference

in

severe

outcomes

was

observed

between

the

two

groups

Also

the

authors

of

a

Finnish

study

conclude

that

selectively

vaginal

breech

deliveries

may

be

safe

in

hospitals

where

the

obstetricians

have

a

tradition

of

vaginal

deliveries

In

their

study

years

of

term

breech

infants

were

delivered

vaginally

When

infants

with

congenital

malformations

were

excluded

they

reported

no

perinatal

deaths

in

their

material

This

is

in

line

with

the

conclusions

of

an

Austrian

observation

study

comprising

breech

presentation

pregnancies

where

of

planned

vaginal

deliveries

actually

went

vaginally

Common

features

of

the

FrenchBelgium

the

Finnish

the

Austrian

and

our

study

include

strict

selection

criteria

for

whom

should

be

offered

vaginal

delivery

close

fetal

monitoring

and

the

presence

of

skilled

obstetricians

The

relatively

high

frequency

of

undiagnosed

breech

presentation

at

birth

in

our

study

has

also

been

found

in

other

studies

supporting

the

importance

of

being

able

to

handle

an

unexpected

breech

delivery

vaginally

The

present

study

is

not

sufficiently

powered

to

demonstrate

differences

in

perinatal

morbidity

or

mortality

between

the

groups

as

these

outcomes

are

rare

In

a

Norwegian

paper

on

breech

deliveries

sample

size

calculation

was

done

based

on

an

anticipated

perinatal

mortality

of

in

the

planned

vaginal

group

and

in

the

cesarean

group

The

authors

concluded

that

a

Nordic

study

similar

to

the

TBT

would

require

a

total

number

of

to

be

recruited

in

each

group

for

twosided

testing

a

number

exceeding

practical

limits

Randomized

controlled

trials

are

considered

as

the

gold

standard

for

clinical

trials

but

the

appropriateness

of

this

design

for

studies

of

complex

clinical

procedures

like

breech

deliveries

has

been

questioned

A

strength

of

the

present

study

is

the

comprehensive

prospective

registration

conducted

by

midwifes

at

our

institution

Furthermore

we

were

able

to

review

the

hospital

records

of

all

the

infants

that

were

admitted

to

the

NICU

after

birth

In

this

study

the

groups

were

compared

according

to

planned

mode

of

delivery

before

onset

of

birth

However

we

have

no

information

on

fetuses

turned

to

cephalic

before

delivery

We

can

not

control

for

all

confounding

factors

including

lack

of

information

about

education

level

and

maternal

pregestational

morbidity

Further

we

can

also

assume

that

there

are

psychological

differences

between

the

groups

as

Furthermore

prelabor

all

women

with

known

breech

presentation

are

counseled

by

experienced

gynecologists

and

selected

to

planned

vaginal

delivery

after

a

thorough

assessment

Go

to

Conclusions

Our

findings

reflect

a

wellfunctioning

health

care

system

where

vaginal

delivery

of

breech

babies

has

been

practiced

even

after

the

results

of

the

TBT

was

published

The

present

study

does

not

have

enough

power

to

make

a

definite

conclusion

that

vaginal

breech

delivery

is

completely

safe

Yet

our

results

indicate

that

vaginal

delivery

of

term

breech

infants

is

acceptable

provided

the

following

conditions

Selection

guidelines

are

followed

the

fetal

monitoring

is

of

high

quality

and

the

volume

of

breeches

delivered

vaginally

is

sufficient

to

maintain

a

high

level

of

competence

among

obstetricians

The

women

should

also

be

counseled

about

the

Go

to

Abbreviations

TBT

Term

Breech

Trial

NICU

Intensive

care

unit

SGA

Small

for

gestational

age

CPAP

Continuous

positive

airway

pressure

STAN

ST

analyses

of

the

fetal

electrocardiogram

ORs

Odds

ratios

CI

Confidence

intervals

SPSS

Statistical

Package

for

Social

Sciences

Go

to

Competing

interests

There

are

no

conflicts

of

interest

for

any

of

the

authors

There

are

no

financial

competing

interests

Go

to

Authors

contributions

IV

contributed

in

acquisition

analysis

and

interpretation

of

data

She

drafted

and

revised

the

manuscript

MC

contributed

in

analysis

and

interpretation

of

data

and

revised

the

manuscript

BLH

contributed

in

acquisition

of

data

and

revision

of

the

manuscript

TH

contributed

in

interpretation

of

data

and

revision

of

the

manuscript

The

four

authors

approved

the

final

version

of

the

manuscript

Go

to

Prepublication

history

The

prepublication

history

for

this

paper

can

be

accessed

here

Go

to

Acknowledgments

The

authors

wish

to

thank

the

midwives

at

Sorlandet

Hospital

for

the

thorough

registration

in

the

breech

database

A

special

thank

to

the

midwives

Hjørdis

Berge

Brekken

and

Bettina

Sundberg

Go

to

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barselomsorg

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O O O O O O O O O O O O O O O O O O O O O O O B I I B I I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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HHS Author Manuscripts PMC3973423 Curr Psychiatry Rep Author manuscript available in PMC 2014 Apr 2 Published in final edited form as Curr Psychiatry Rep 2013 Jan 151 335 doi 101007s1192001203352 PMCID PMC3973423 NIHMSID NIHMS559334 Components of Emotion Dysregulation in Borderline Personality Disorder A Review Ryan W Carpenter and Timothy J Trull Author information Copyright and License information The publishers final edited version of this article is available at Curr Psychiatry Rep See other articles in PMC that cite the published article Abstract Following Linehans biosocial model we conceptualize emotion dysregulation in borderline personality disorder BPD as consisting of four components emotion sensitivity heightened and labile negative affect a deficit of appropriate regulation strategies and a surplus of maladaptive regulation strategies We review the evidence supporting each of these components Given the complexity of the construct of emotion dysregulation and its involvement in many disorders there is a need for research that specifies which components of emotion dysregulation are under study and also examines the interplay amongst these emotion dysregulation components Keywords Borderline personality disorder BPD Emotion sensitivity Biosocial theory Affective instability Negative affect Emotion regulation Distress tolerance Emotion dysregulation Emotion regulation strategies Inadequate appropriate regulation strategies Maladaptive regulation strategies Psychiatry Go to Introduction Borderline personality disorder is a serious mental disorder that is present in in 1 3 of the general population and clinically is the most commonly diagnosed personality disorder present in 10 of patients in outpatient settings 1520 of patients in inpatients settings and 3060 of patients diagnosed with personality disorders 1 2 3 Although often considered a disorder of dysregulation including dysregulation in the areas of interpersonal relationships behavior identity and cognition emotion dysregulation is considered to lie at the core of the disorder 4 5 6 7 Emotion dysregulation is the inability to flexibly respond to and manage emotions Although this definition may appear straightforward there is considerable variation in the phenomena studied under the heading of emotion dysregulation in BPD Some researchers have focused on emotion sensitivity others on affective intensity or affective lability still others on emotional vulnerability and so on This is not especially surprising given the complexity of the construct One way to understand these disparate approaches is to view emotion dysregulation as a process incorporating multiple interactive components and not as an endstate 8 According to Linehans biosocial theory 4 5 individuals with BPD are emotionally sensitive from birth This sensitivity leads to a propensity to experience negative affect across contexts and situations which then makes it difficult to learn appropriate emotion regulation strategies This deficit in appropriate regulation strategies likely contributes to a tendency to engage in dysregulated behaviors in order to manage and reduce negative affect This four component process results in negative consequences which in turn reinforce emotion sensitivity The result is a recursive pattern of emotion dysregulation Multicomponent model of emotion dysregulation in BPD Individuals with BPD are theorized to be sensitive to emotional stimuli from birth Experiencing a negatively valenced stimulus or interpreting a stimulus in a negative way in the environment leads The present article takes this multicomponent model of emotion dysregulation as its organizational framework Instead of focusing on the broad construct of emotion dysregulation we briefly review the evidence for each of the four components implicated in the biosocial model Emotion sensitivity heightened and labile negative affect a deficit of appropriate regulation strategies and a surplus of maladaptive regulation strategies Note that although a consideration of these components provides the groundwork for a dynamic process model of emotion dysregulation at present there is not enough empirical evidence to detail the interplay and direction of influence of these components After reviewing Go to Emotion Sensitivity Emotion sensitivity the first component of our model is thought to have biological origins and to be present from early life 4 5 It consists of a heightened emotional reactivity to environmental stimuli including emotions of others Emotion sensitivity in BPD has primarily been associated with negative mood states eg anger fear sadness and not positive emotions although see 9 10 Along these lines Carlson Egeland and Sroufe 11 found in a prospective longitudinal study of 162 individuals that measures of negative emotionality a construct presumably influenced by emotion sensitivity in early childhood and adolescence predicted later BPD symptoms Many studies of emotion sensitivity in individuals with BPD have employed traditional laboratorybased cognitive tasks using emotional stimuli For example in the typical Stroop task 12 individuals are presented with words displayed in different colors and must ignore the word itself but name the color In the emotional Stroop task the words vary on their emotional significance Theoretically individuals sensitive to emotionally charged stimuli should have more difficultly suppressing their inclination to read the words slowing their reaction times Some studies have found that BPD individuals have slower reaction times on the emotional Stroop task 9 10 13 however others did not 14 16 Although Wingenfeld et al 16 did not find any significant reaction time differences between individuals with BPD and controls except that the BPD group was slower overall they found suggestive betweengroup differences in brain activity Specifically they found that the control group showed increased activation in the anterior cingulate cortex ACC and frontal lobe during the task while the BPD group did not This effect was particularly strong in controls when the negative stimuli were selected specifically to relate to a stressful event participants had selfreported before the experiment The findings indicated that BPD individuals may have a cognitive and especially attentional bias toward processing Studies of emotion recognition in BPD individuals similarly suggest a negativity bias in emotion recognition for a review see 17 That is BPD individuals appear to be biased toward identifying negative emotions in others 18 21 This is despite or in conjunction with a tendency to be less accurate in correctly identifying emotions in facial stimuli 22 25 The mixed findings concerning overall accuracy in identifying emotions may be due to the different types of stimuli used eg social versus nonsocial different instructions offered and different emotions examined 26 Go to Negative Affect The second component of emotion dysregulation in BPD is experiencing high levels of negative affect This is theorized to be a direct consequence of emotion sensitivity which as stated above has been primarily demonstrated to be specific to sensitivity toward negative mood states 27 Findings suggest that negative affect is strongly associated with BPD 28 29 in terms of both intensity and reactivity as assessed by selfreport and psychophysiological measures 30 Individuals with BPD appear to experience more negative affect on average than individuals without BPD eg 22 31 but the evidence is somewhat inconsistent and differences are not always large eg 27 32 33 However the most important characteristic of negative affect in BPD is perhaps not its absolute level but its instability over time and particularly its ability to intensify rapidly and without much warning This too is a likely result of emotion sensitivity as the high level of reactivity to environmental stimuli in BPD individuals especially toward events that are subtle or may seem innocuous to individuals without BPD would be expected to cause rapid changes in mood The assessment of affective instability in BPD requires a more nuanced assessment approach than what traditional clinical assessment approaches eg crosssectional assessment retrospective assessment can provide because affective instability is a dynamic timedependent process 34 Methods like ecological momentary assessment EMA 35 however can provide multiple assessments of mood per day over many days 36 and reveal acute increases in negative affect from one moment or occasion to the next 33 This highfrequency assessment approach yields intensive longitudinal data 37 This is the only way to precisely assess the dynamics of mood states extreme changes of mood and environmental triggers for mood changes Approaches that involve retrospective assessment of mood or mood changes are limited as are traditional trait questionnaire approaches 38 Individuals are notoriously poor historians even for significant events and experiences Asking individuals to aggregate experiences across time as retrospective approaches do is even more dubious eg to rate themselves on the frequency and intensity of an unstable process like affective instability An added advantage of EMA is that mood states are assessed in the persons natural habitat In other words we are able to obtain a more ecologically valid assessment of a persons mood in his or her daily life 39 while at the same time sampling experiences and events that may serve as antecedents covariates or consequences of mood changes 34 This focus on ecological validity differentiates daily life sampling methods like EMA from laboratorybased assessments of emotional dysregulation For example there are laboratory paradigms for eliciting emotional reactions eg using pictures and films and the individuals reactions can be assessed using brain imaging coding of facial expression or physiological response However in each case it is unclear how such findings translate into realworld experiences EMA studies generally find greater instability of negative affect in BPD for a review see 31 Here we discuss two more recent EMA studies of the instability of negative affect in BPD EbnerPriemer et al 40 suggested that previous diary studies of affective instability in BPD had found mixed results because of the methods used by these studies to measure affective instability They recruited 50 participants with BPD and 50 controls who carried an electronic diary with them for 24 hrs Participants were prompted every 1020 minutes to answer questions about their current emotional state For their analyses EbnerPriemer et al 40 identified three components of instability that needed to be taken into account Amplitude whether changes are large or small frequency whether changes are rare or frequent and temporal dependency or in what sequence changes occur 41 Previous analyses had largely overlooked amplitude and temporal dependency Ebner et al 40 used mean squared successive difference MSSD scores which weight larger successive changes more and thereby account for amplitude and temporal dependency and found that individuals with BPD were more unstable on scores of emotional valence and distress They also found that BPD individuals were prone to large decreases in positive mood and that about half of these sudden decreases resulted in a negative mood state compared to only 9 of the declines in healthy controls Trull et al 33 compared participants with BPD or major depressive disorder MDD over 28 days Participants carried electronic diaries and reported on their positive and negative mood up to six times per day Due to the multiple assessments for each individual per day Trull et al 33 used multilevel modeling to account for differences between groups of participants BPD participants displayed more variability over time in both positive and negative affect Using MSSDs adjusted for length of time interval between assessments they found BPD individuals showed more instability of hostility fear and sadness but not positive affect or general negative affect Those with BPD were also more likely to report extreme changes for hostility scores Interestingly BPD individuals did not report greater mean levels of positive or negative emotions than MDD individuals In sum Trull et al 33 extended the findings of EbnerPriemer et al 40 finding greater instability of specific negative affects over a longer period of time and in comparison to a clinical control group Go to Inadequate Emotion Regulation Strategies The third component of emotion dysregulation in BPD is a deficit in appropriate emotion regulation strategies Negative affect is an inescapable part of everyday life for individuals with and without BPD The majority of individuals without BPD are more or less able to manage their negative emotions most of the time with relative success According to the biosocial theory however individuals with BPD as emotionallysensitive children experiencing heightened negative affect did not learn the necessary skills to regulate emotion As a result they have difficulties with controlling what emotions they have when they have them and how those emotions are 42 Thus strategies of emotion regulation can be targeted at shaping emotions before they occur or at modulating the emotion after it has begun 43 We focus specifically on lack of adaptive strategies in this section distinguishing them from maladaptive strategies covered in the next section As already noted the ability to identify what emotions one is experiencing is an important part of emotion regulation Individuals with BPD have lower emotional awareness 44 Similar to emotional awareness is the ability to distinguish among emotional states called emotional granularity 45 Those high in emotional granularity are able to reliably and accurately differentiate their emotional states eg distinguish sadness from anger In contrast those low in emotion granularity tend to describe emotional states in more global terms eg feeling good or feeling bad Suvak et al 46 recently evaluated emotional granularity in 46 individuals diagnosed with BPD and compared their performance to that of 51 controls Results indicated that BPD individuals scored significantly lower than controls on measures of emotional clarity mood labeling and emotional labeling focused on arousal versus valence In the same vein a recent EMA study found that BPD individuals experienced greater polarity ie allornothing in their affect 47 These findings are consistent with clinical observations that those with BPD have more difficulty identifying differentiating and labeling emotions especially if they are of the same valence In addition to recognizing and labeling their emotions individuals with BPD have been found to have more problems employing emotion regulation strategies based on both selfreport and behavioral measures 48 51 and neuroimaging studies 52 53 Low levels of distress tolerance 54 are also associated with BPD 50 suggesting that those with BPD have not developed coping strategies to manage episodes of aversive tension or unease We discuss two recent studies that have found empirical support suggesting that deficits in adequate emotion regulation and distress tolerance play an important role in the development of BPD Salsman and Linehan 55 investigated whether selfreported problems with emotion regulation as measured by the Difficulties in Emotion Regulation Scale DERS 56 were indirectly associated with selfreported BPD symptoms when negative affect was accounted for They recruited 456 undergraduates from two geographic locations and found that the limited access to emotion regulation strategies factor was associated with BPD symptoms both when affect intensity and affective reactivity were accounted for Other studies have found a similar effect for total DERS scores on the association between negative affect on BPD symptoms in both inpatients and undergraduates 51 57 These findings support the idea that the inability to appropriately manage affect is an important contributor to BPD Extending these findings Bornovalova Matusiewicz and Rojas 58 examined whether distress tolerance might moderate the relationships of negative emotionality and negative affect intensity on Personality Assessment InventoryBorderline Features PAIBOR 59 scores To measure distress tolerance they used two laboratory tasks designed to induce frustration and dysphoria from which a composite score was created They recruited 110 adult smokers from the community and 76 inpatient substance users Findings suggested that there was an additive effect for distress tolerance on negative emotionality such that negative emotionality was associated with PAIBOR scores regardless of distress tolerance scores but individuals with the lowest distress tolerance showed the strongest association However for affect intensity there was a relationship with PAIBOR scores only in individuals with low distress tolerance Unfortunately they did not test the cumulative Negative emotionality defined as a heritable trait reflecting a tendency to experience negative affect is likely influenced by an emotion sensitivity bias reviewed above These findings suggest then that the ability to tolerate distress confers some protection against developing BPD symptoms but more so in individuals who experience intense negative affect than those who are emotionally sensitive This hints at possibly complex interplay between the different components of emotion dysregulation in individuals with BPD On that same note when broken down according to the subscales of the PAIBOR findings were only significant for the selfharm subscale suggesting that individuals who Go to Maladaptive Regulation Strategies The final component of emotion dysregulation is the behavior that may occur instead of appropriate emotion regulation strategies leading to emotion dysregulation problems that may be observed by others One explanation of how these behaviors emerge is offered by the emotional cascade model 60 This model hypothesizes that if negative affect becomes sufficiently intense individuals tend to choose maladaptive behaviors over adaptive ones This may be because maladaptive behaviors often have a more immediate effect or are simpler to employ than more adaptive ones Yet although such maladaptive behavior may be effective at reducing negative affect it is ultimately problematic either because of negative consequences because it is not effective over the longterm or both Selby et al 61 found support for this model in individuals with BPD Similarly Coifman et al 47 found that greater polarity of affect in the absence of interpersonal stress predicted increased reports of impulsive and selfinjurious behaviors There is a great deal of evidence that BPD individuals engage in maladaptive regulation strategies in an attempt to reduce their negative affect BPD has been linked to maladaptive cognitive strategies such as rumination 61 62 and thought suppression 63 64 which often increase instead of decrease negative affect Research also suggests that BPD is associated with experiential avoidance defined as behavior engaged in to escape an unwanted experience such as negative affect 65 66 Two types of behaviors that are common in BPD are impulsive and suicidal and selfinjurious behaviors Here we review the evidence that individuals with BPD engage in impulsive behaviors and suicidal and selfinjurious behavior SIB specifically as a means of affect regulation In general BPD is associated with a number of impulsive behaviors that may serve to reduce negative affect including eating disorders impulsive buying and substance use for example BPD is also strongly associated with the Urgency subscale of the UPPS Impulsivity Scale 67 although it is associated with other subscales of impulsivity as well 68 The Urgency subscale is closely linked to negative affect and refers to the tendency for individuals to act impulsively while in a negative mood potentially in an attempt to relieve or reduce their negative affect Tragesser and Robinson 69 found that selfreported affective instability and urgency as well as lack of premeditation uniquely predicted scores on the PAIBOR in a sample of undergraduates From a neurobiological perspective Silbersweig et al 70 found that BPD individuals showed decreased activation in the ventromedial prefrontal cortex relative to controls in an emotional linguistic gonogo task requiring behavioral inhibition but only on trials involving negativelyvalenced words This suggests that this region of the brain might play a role in the tendency for individuals with BPD to act impulsively in the context of negative affect Conversely Chapman Leung and Lynch 49 found that BPD individuals in a negative emotional state committed fewer impulsive responses on a passive avoidance learning task than BPD individuals not in a negative emotional state However this may have been because of the nature of the task in which stimuli were associated with either reward or punishment and participants had to learn to respond or inhibit responding accordingly It is difficult to see how acting impulsively on such a task would be tied to negative affect thereby giving BPD individuals no incentive to act impulsively Regarding suicidality Yen et al 29 found that affective instability along with identity disturbance and impulsivity predicted suicidal behaviors and with childhood sexual abuse was a predictor of suicide attempts There is also evidence that SIB serves as a method of emotion regulation in BPD SIB is defined as behavior that intentionally damages the body without lethal intent and includes a range of actions eg cutting burning scratching Between 50 and 90 of individuals with BPD engage in SIB 71 72 By far the most common reason individuals with BPD give when asked why they engage in SIB is that it reduces feelings of negative affect and helps regulate their mood 73 Interestingly individuals with BPD report little or no pain when engaging in SIB or during paininduction tasks 74 80 This effect appears to be even greater when participants are experiencing distress 74 75 Franklin and colleagues 81 found that emotion dysregulation mediated the relationship between SIB and pain tolerance although they did not use a BPD sample Recently Niedtfeld et al 82 attempted to unravel the neurobiological link between pain and emotion regulation in BPD Reanalyzing inconclusive data from Niedtfeld et al 77 they examined the functional connectivity between paralimbic and prefrontal brain structures in individuals with BPD after painful stimulation Following negative stimulus pictures BPD patients showed a negative coupling between paralimbic and prefrontal regions possibly indicating that prefrontal areas inhibited paralimbic regions following pain in this group Controls showed this same pattern but only following neutral pictures Go to Conclusion Having reviewed the four principal components of emotion dysregulation in BPD as defined by Linehans biosocial model 4 5 it is clear that there are multiple ways of investigating the topic of emotion dysregulation The available evidence supports the importance of each of these components in BPD From our review we can conclude that evidence supports a negative bias in identifying emotions in others and presumably in evaluating others Such a bias is likely to lead to more intense negative affect in those with BPD and in particular affective instability and reactivity to both events and to others that are encountered in daytoday life Unfortunately those with BPD are relatively unable to tolerate the distress that is encountered in Unfortunately many researchers invoke emotion dysregulation without mention of specific components or otherwise clearly defining their use of the term This can make it difficult to put different studies into context as they work from different starting points employ different methods obtain different outcomes and yet all purport to study emotion dysregulation For example we have demonstrated that sensitivity to emotional stimuli in this case a negative interpretation bias and labile negative affect are two distinguishable constructs but the terms emotion sensitivity and affective instability are both often considered as synonymous and interchangeable with emotion dysregulation This practice is short on nuance and has negative consequences for the field First it threatens to render the term emotion dysregulation vague and perhaps meaningless To say that BPD is associated with emotion dysregulation is similar to saying that individuals with BPD have problems with their emotions This puts those with BPD in the same category as individuals with depression anxiety bipolar disorder schizophrenia autism spectrum disorder and even many others who do not meet criteria for a psychiatric disorder Conversely to say that BPD is associated with an emotion dysregulation process that consists of emotion sensitivity heightened negative That is not to say that the model provided here is the best or even penultimate model of emotion dysregulation in BPD or that it is necessarily complete There may be additional areas of emotion dysregulation that BPD individuals struggle with or perhaps some researchers might differentiate between constructs we included within the same component For example emotional awareness could be considered distinct from emotion regulation skills Our decisions on how to define each component are admittedly somewhat subjective and the full model itself has not been tested empirically The important takeaway point however is that as research on emotion Second defining emotion dysregulation in vague terms likely obscures the interrelationships between the different components of emotion dysregulation Although some have investigated the relationship between multiple components eg the emotional cascade model proposes a mechanism for how heightened negative affect leads to maladaptive regulation strategies most studies have focused on only one component A more precise and dynamic view of emotion dysregulation brings to the forefront questions about how problems in each component develop over time and how emotion dysregulation in BPD is different from emotion dysregulation in other disorders Research is needed that assesses multiple emotion dysregulation components within In summary emotion dysregulation is a complex process and one that appears to be core to the disorder of BPD It is also a process that develops over the lifetime likely beginning in infancy We have proposed an organizational structure of the components of emotion dysregulation derived from Linehans biosocial theory 4 5 Emotion sensitivity heightened negative affect a deficit of appropriate regulation strategies and a surplus of maladaptive regulation strategies We believe that there are important benefits for research that first specifies those aspects of emotion dysregulation under study and second examines these components in the context of other emotion dysregulation components Go to Footnotes Disclosure No potential conflicts of interest relevant to this article were reported Go to Contributor Information Ryan W Carpenter University of Missouri Columbia USA Timothy J Trull University of Missouri Columbia USA Department of Psychological Sciences University of Missouri 210 McAlester Hall Columbia MO USA Go to References Papers of particular interest published recently have been highlighted as Of importance Of major importance 1 Lenzenweger MF Lane MC Loranger AW Kessler RC DSMIV personality disorders in the national comorbidity survey replication Biol Psychiatry 2007 62 55364 PMC free article PubMed 2 Trull TJ Jahng S Tomko RL et al Revised NESARC personality disorder diagnoses gender prevalence and comorbidity with substance dependence disorders J Pers Disord 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O O O O O O O O O O O O O O O B I O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I I O O O O O O O O O O O O O O O O O O O O O O O B I O B I I O O O O O O O O O O O O O O O O O O O O O O B I O B I I O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O

emotion dysregulation
borderline personality disorder