Remnants and changes in facial emotion processing in women with remitted borderline personality disorder: an EEG study

The Hypothalamus-Pituitary-Adrenal Axis and Social Cognition in Borderline Personality Disorder

Borderline personality disorder (BPD) is characterized by emotional instability, impulsivity and unstable interpersonal relationships. Patients experience discomforting levels of distress, inducing symptoms like dissociation, aggression or withdrawal. Social situations are particularly challenging, and acute social stress can reduce patients' cognitive and social functioning. In patients with Major Depressive Disorder or Posttraumatic Stress Disorder, which show high comorbidity with BPD, the endocrine stress response is characterized by Hypothalamus-Pituitary-Adrenal (HPA) axis dysfunction, which affects cognitive functioning. Compared to these clinical groups, research on HPA-axis function in BPD is relatively scarce, but evidence points towards a blunted cortisol reactivity to acute stress. Since BPD patients are particularly prone to social stress and experience high subjective difficulties in these situations, it seems plausible that HPA-axis dysregulation might contribute to decreased social cognition in BPD. The present review summarizes findings on the HPA-axis function in BPD and its association with social cognition following acute social stress. For this purpose, we review literature that employed a widely used social stressor (Trier Social Stress Test, TSST) to study the effects of acute social stress on social cognition and the HPA-axis response. We contrast these findings with studies on social cognition that employed Cyberball, another widely used social stressor that lacks HPA-axis involvement. We conclude that research on social cognition in BPD reveals heterogeneous results with no clear relationship between social functioning and HPA-axis response. More research is needed to better understand the psychophysiological underpinnings of impaired social cognition in BPD.

Trustworthiness judgments and Borderline Personality Disorder: an experimental study on the interplay of happiness and trustworthiness appraisals and the effects of wearing face masks during the Covid-19 pandemic in Germany

BACKGROUND

Judging positive emotional states or the trustworthiness of others is important for forming and maintaining social affiliations. Past studies have described alterations in these appraisal processes in Borderline Personality Disorder (BPD), which might have been exacerbated during the Covid-19 pandemic by the requirement to wear face masks. In the present study, we investigated in an online-survey a) whether social judgments are particularly strongly affected in individuals with BPD when they have to judge happiness and trustworthiness in facial stimuli covered by a mask, b) whether appraising a positive emotional state affects trustworthiness appraisals differentially in BPD and healthy individuals and c) whether social judgments are related to how individuals with BPD experience wearing masks during the pandemic.

METHODS

Participants (67 HC, 75 BPD) judged happiness and trustworthiness of faces with calm expression with and without masks. Additionally, data on participants' confidence in their judgments, the experience of the burden induced by wearing masks, the protective benefits of masks, and compliance to wearing masks were collected.

RESULTS

Happiness and trustworthiness were evaluated less confidently and less intense in the BPD group compared to HC. Masks reduced happiness and trustworthiness ratings in both groups. Lower happiness appraisals contributed to lower trustworthiness appraisals except for those with BPD and low levels of symptom severity. Lower trustworthiness ratings were associated with a higher burden, attributing a lower benefit to masks and lower compliance with wearing masks in BPD.

CONCLUSIONS

Masks do not exacerbate deficits in social judgments. However, lower trustworthiness appraisals in general were linked with more negative evaluations of wearing masks in the BPD group.

TRIAL REGISTRATION

The aims and hypotheses were preregistered together with the design and planned analyses ( https://aspredicted.org/f5du7.pdf ). For findings of an additionally preregistered research question on the impact of adverse childhood experiences see supplementary material.

Social Touch, Social Isolation, and Loneliness in Borderline Personality Disorder During the COVID-19 Pandemic

BACKGROUND

Interpersonal impairments in borderline personality disorder (BPD) are characterised by a lack in the sense of belonging and the fear of being excluded. One feature of interactions that can promote a sense of social belonging is interpersonal touch. While some studies suggest that individuals with BPD experience social touch as less pleasurable than healthy individuals (HCs), there are no studies that investigated whether this difference is associated with feeling less socially connected. This question is particularly important during the COVID-19 pandemic, since one central behavioural recommendation is "social distancing". An increase in loneliness has been discussed as a consequence and it has been suggested that individuals with BPD may be particularly burdened. However, the primary goal of "social distancing" is not preventing social contacts, but physical proximity. In our study we investigated the interplay between feeling close to others, contact frequency and the appraisal of social touch in BPD. We were additionally interested in whether these factors contribute to the burden through "physical distancing".

METHODS

We assessed subjective and objective social isolation, the need, importance, and liking of social touch, as well as the burden through "physical distancing" policies in 130 women (61 BPD and 69 HCs).

RESULTS

Participants of the BPD group reported higher loneliness, less social contacts and a lower need for, importance and liking of social touch compared to HCs. Larger social networks, higher frequency of in-person contacts and higher liking and importance of social touch were associated with lower levels of loneliness. Both groups did not differ regarding their burden through "physical distancing". A higher need for and lower importance of social touch predicted a higher burden through "physical distancing".

CONCLUSIONS

A positive appraisal of social touch was associated with less loneliness, independently of an individual's objective social isolation. In BPD, impairments of this fundamental facet of social interaction might hamper forming and strengthening of social bonds and contribute to the patients' interpersonal dysfunction. Changing the attitude towards social touch and in consequence its liking and importance in social interaction might provide one avenue to improve the sense of social connectedness in these patients.

Behavioral and neurophysiological correlates of emotional face processing in borderline personality disorder: are there differences between men and women?

Emotional dysregulation is a core feature of borderline personality disorder (BPD); it is, for example, known to influence one's ability to read other people's facial expressions. We investigated behavioral and neurophysiological foundations of emotional face processing in individuals with BPD and in healthy controls, taking participants' sex into account. 62 individuals with BPD (25 men, 37 women) and 49 healthy controls (20 men, 29 women) completed an emotion classification task with faces depicting blends of angry and happy expressions while the electroencephalogram was recorded. The cortical activity (late positive potential, P3/LPP) was evaluated using source modeling. Compared to healthy controls, individuals with BPD responded slower to happy but not to angry faces; further, they showed more anger ratings in happy but not in angry faces, especially in those with high ambiguity. Men had lower anger ratings than women and responded slower to angry but not happy faces. The P3/LPP was larger in healthy controls than in individuals with BPD, and larger in women than in men; moreover, women but not men produced enlarged P3/LPP responses to angry vs. happy faces. Sex did not interact with behavioral or P3/LPP-related differences between healthy controls and individuals with BPD. Together, BPD-related alterations in behavioral and P3/LPP correlates of emotional face processing exist in both men and women, supposedly without sex-related interactions. Results point to a general 'negativity bias' in women. Source modeling is well suited to investigate effects of participant and stimulus characteristics on the P3/LPP generators.

Reduced habenular volumes and neuron numbers in male heroin addicts: a post-mortem study

The Habenula is increasingly being investigated in addiction. Reduced volumes of other relevant brain regions in addiction, such as nucleus accumbens, globus pallidus and hypothalamus have been reported. Reduced volumes of the habenula as well as reduced neuronal cell count in the habenula have also been reported in mood disorders and an overlap between mood disorders and addiction is clinically widely recognized. Thus, our aim was to investigate possible volume and neuronal cell count differences in heroin addicts compared to healthy controls. Volumes of the medial (MHB) and lateral habenula (LHB) in heroin addicts (n = 12) and healthy controls (n = 12) were assessed by morphometry of 20 µm serial whole brain sections. Total brain volume was larger in the heroin group (mean 1466.6 ± 58.5 cm³ vs. mean 1331.5 ± 98.8 cm³), possibly because the heroin group was about 15 years younger (p = 0.001). Despite larger mean whole brain volume, the mean relative volume of the MHB was smaller than in healthy non-addicted controls (6.94 ± 2.38 × 10^-6 vs.10.64 ± 3.22 × 10^-6; p = 0.004). A similar finding was observed regarding relative volumes of the LHB (46.62 ± 10.90 × 10^-6 vs. 63.05 ± 16.42 × 10^-6 p = 0.009). In parallel, neuronal cell numbers were reduced in the MHB of heroin-addicted subjects (395,966 ± 184,178 vs. 644,149 ± 131,140; p < 0.001). These findings were not significantly confounded by age and duration of autolysis. Our results provide further evidence for brain-structural deficits in heroin addiction.

[Neurobiological principles of borderline personality disorder: integration into the ICD-11 model of personality disorders]

BACKGROUND

Borderline personality disorder (BPD) is a severe mental disorder associated with far-reaching impairments in the self and interpersonal functioning. The broad database has contributed to the fact that BPD remains the only categorical personality diagnosis in ICD-11, even if coupled to the determination of the severity of impairments. Nevertheless, we need to deal with a dimensional conceptualization of personality disorders-which is also supported by neuroscientific findings-at the latest in 2022 when the ICD-11 comes into effect .

OBJECTIVE

This narrative review provides an overview of neuroscientific findings regarding impairments in self and interpersonal functioning in patients with BPD.

RESULTS

Alterations in the medial prefrontal cortex, temporoparietal junction and precuneus mediate deficits in self-referential thought processes and the mentalization of emotions and intentions of others. Enhanced connectivity between the amygdala and midline structures is associated with hypermentalization. At the same time, elevated insula activation seems to underlie the strengthened nonreflective parts of feelings of other people. Frontolimbic alterations are transdiagnostically associated with deficient emotional regulation and negative affectivity and alterations in reward and cognitive control regions are related to impulsivity.

CONCLUSION

Neuroscientific findings help to have a better understanding of the underlying mechanisms of central functional impairments in BPD and can support the transition to ICD-11 as well as the implementation of new interventions.

A systematic review and meta-analysis of 'Systems for Social Processes' in borderline personality and substance use disorders

Deficits in social processing (SP) have been proposed to underpin interpersonal dysfunction in both Borderline Personality Disorder (BPD) and Substance Use Disorders (SUD). This study aimed to explore potential transdiagnostic cognitive and behavioral phenotypes of these disorders utilizing the NIMH Research Domain Criteria 'Systems for Social Processes'. A systematic review and meta-analysis of the published research was conducted on 134 studies identified through our database searches. Four meta-analyses were conducted, which revealed significant overlapping deficits in the ability to identify facial emotions and infer the mental states of others in both BPD and SUD. Further, people with BPD displayed a higher ostracism effect following perceived social exclusion. Systematically reviewed studies also revealed significant dysfunction amongst individuals with BPD and SUD across both self and other SP constructs, which were broadly similar in magnitude. Taken together, these results support the proposition that SP dysfunction may be considered a core transdiagnostic phenotype of BPD and SUD.

An eye-tracking study of interpersonal threat sensitivity and adverse childhood experiences in borderline personality disorder

BACKGROUND

Previous eye-tracking studies provide preliminary evidence for a hypersensitivity to negative, potentially threatening interpersonal cues in borderline personality disorder (BPD). From an etiological point of view, such interpersonal threat hypersensitivity might be explained by a biological vulnerability along with a history of early life adversities. The objective of the current study was to investigate interpersonal threat hypersensitivity and its association with adverse childhood experiences (ACE) in patients with BPD employing eye-tracking technology.

METHODS

We examined a sample of 46 unmedicated, adult female patients with BPD and 25 healthy female volunteers, matched on age and intelligence, with a well-established emotion classification paradigm with angry, fearful, happy, and neutral facial expressions. ACE were assessed retrospectively with the Childhood Trauma Questionnaire.

RESULTS

Patients as compared to healthy volunteers reflexively directed their gaze more quickly towards the eyes of emotional and neutral faces and did not adapt their fixation patterns according to the facial expression presented. Misclassifying emotional and neutral faces as angry correlated positively with the patients' self-reported ACE.

CONCLUSIONS

Building on and extending earlier findings, our results are likely to suggest a visual hypervigilance towards the eyes of emotional and neutral facial expressions and a childhood trauma-related anger bias in patients with BPD. Given the lack of a clinical control group, the question whether these findings are specific for BPD has to remain open. Thus, further research is needed to elucidate the specificity of altered visual attention allocation and the role of ACE in anger recognition in patients with BPD.

Facial emotion recognition in borderline patients is unaffected by acute psychosocial stress

Borderline Personality Disorder (BPD) is characterized by difficulties in social cognition and social interactions, which exacerbate under stress. A previous study found better facial emotion recognition (FER) in patients with personality disorders and healthy controls (HC) after stress. We recently reported that emotional empathy scores, i.e. the emotional response to another person's emotional state, were significantly lower in BPD patients than in HC after psychosocial stress. Cognitive empathy scores remained unaltered. The present study aims to further investigate the effect of psychosocial stress induced by the Trier Social Stress Test (TSST) on FER as part of social cognition in patients with BPD. We randomized 43 women with BPD and 46 female HC to either the TSST or a placebo condition. Afterwards, participants were asked in an emotion recognition test to identify emotions in faces showing anger or sadness at low and high intensity. Both groups recognized emotions better at high intensity compared with low intensity. There was no effect of stress on FER performance and we found no difference between groups. This is in line with prior research on social cognition in BPD patients demonstrating that the ability to understand another person's perspective might be unaffected by acute stress.

Evidence for Altered Neural Processing in Patients With Borderline Personality Disorder

Abstract. Borderline personality disorder (BPD) is characterized by difficulties in emotion regulation, self-identity disturbances, self-injurious behavior, and reduced inhibitory control. Event-related potential (ERP) studies have sought to reveal the neural correlates of cognitive distortions and behavioral alterations in BPD. The article presents an overview of the existing ERP literature pertaining to BPD and discusses whether any one of the electrophysiological findings could serve as a reliable and specific marker for BPD. In short, ERP studies investigating P300 tentatively suggest impaired inhibitory control. Moreover, reduced error- and feedback-related processing and impaired response inhibition seem to be associated with impulsivity and risk-taking behavior in BPD patients. However, these findings are not specific for BPD. Regarding emotional and self-referential information processing, individuals with BPD display heightened vigilance toward social threat impacting their cognitive performance in various social-cognitive tasks demonstrating alterations of early negative and late positive potentials. These multifaceted electrophysiological alterations may be attributed to dysfunctional activity and connectivity of frontal brain regions and the limbic system.

A negative bias in decoding positive social cues characterizes emotion processing in patients with symptom-remitted Borderline Personality Disorder

BACKGROUND

Impairments in the domain of interpersonal functioning such as the feeling of loneliness and fear of abandonment have been associated with a negative bias during processing of social cues in Borderline Personality Disorder (BPD). Since these symptoms show low rates of remission, high rates of recurrence and are relatively resistant to treatment, in the present study we investigated whether a negative bias during social cognitive processing exists in BPD even after symptomatic remission. We focused on facial emotion recognition since it is one of the basal social-cognitive processes required for successful social interactions and building relationships.

METHODS

Ninety-eight female participants (46 symptom-remitted BPD [r-BPD]), 52 healthy controls [HC]) rated the intensity of anger and happiness in ambiguous (anger/happiness blends) and unambiguous (emotion/neutral blends) emotional facial expressions. Additionally, participants assessed the confidence they experienced in their own judgments.

RESULTS

R-BPD participants assessed ambiguous expressions as less happy and as more angry when the faces displayed predominantly happiness. Confidence in these judgments did not differ between groups, but confidence in judging happiness in predominantly happy faces was lower in BPD patients with a higher level of BPD psychopathology.

CONCLUSIONS

Evaluating social cues that signal the willingness to affiliate is characterized by a negative bias that seems to be a trait-like feature of social cognition in BPD. In contrast, confidence in judging positive social signals seems to be a state-like feature of emotion recognition in BPD that improves with attenuation in the level of acute BPD symptoms.

Borderline personality disorder

Caretakers are often intimidated or alienated by patients with borderline personality disorder (BPD), compounding the clinical challenges posed by the severe morbidity, high social costs and substantial prevalence of this disorder in many health-care settings. BPD is found in ∼1.7% of the general population but in 15-28% of patients in psychiatric clinics or hospitals and in a large proportion of individuals seeking help for psychological problems in general health facilities. BPD is characterized by extreme sensitivity to perceived interpersonal slights, an unstable sense of self, intense and volatile emotionality and impulsive behaviours that are often self-destructive. Most patients gradually enter symptomatic remission, and their rate of remission can be accelerated by evidence-based psychosocial treatments. Although self-harming behaviours and proneness to crisis can decrease over time, the natural course and otherwise effective treatments of BPD usually leave many patients with persistent and severe social disabilities related to depression or self-harming behaviours. Thus, clinicians need to actively enquire about the central issues of interpersonal relations and unstable identity. Failure to correctly diagnose patients with BPD leads to misleading pharmacological interventions that rarely succeed. Whether the definition of BPD should change is under debate that is linked to not fully knowing the nature of this disorder.

Behavioral and Neurobiological Correlates of Disturbed Emotion Processing in Borderline Personality Disorder

One of the core symptoms of borderline personality disorder (BPD) is emotion dysregulation, which comprises emotion sensitivity, heightened and labile negative affect, deficient appropriate regulation strategies, and a surplus of maladaptive regulation strategies. Although earlier studies provided some evidence for threat hypersensitivity in terms of a negatively biased perception of other people ("negativity bias") and deficits in the recognition of full-blown anger, i.e., higher error rates and slower reaction times, researchers have only recently started studying effects of interindividual differences (e.g., sex, impulsivity, aggressiveness) and stimulus complexity as well as associations with early adversity, developmental aspects, or the specificity for BPD. Recent data also suggest a deficit in the detection of positive emotions, which needs to be addressed in more detail since it may prevent the patients from recognizing safety signals and from making positive interpersonal experiences. Neurobiologically, threat hypersensitivity has been related to increased and prolonged amygdala responses, while deficient emotion regulation was associated with reduced prefrontal inhibition of the amygdala. First results suggest that these neural alterations may be modulated by psychotherapeutic treatment focusing on emotion regulation.

Neurobiological Mechanisms Mediating Emotion Dysregulation as Targets of Change in Borderline Personality Disorder

Emotion dysregulation is a hallmark of borderline personality disorder (BPD). Most interventions for patients with BPD, therefore, aim at the improvement of emotion regulation. In the current paper, we provide an overview of studies investigating the effects of psychotherapeutic or pharmacological interventions on neurobiological correlates of various aspects of emotion regulation. In fact, studies suggest that the prefrontal-limbic circuit may play a major role in mediating effects of clinically efficacious psychotherapeutic treatments, i.e., they lead to clinical improvement via modulating the function and structure of the amygdala, the insula, and the dorsal anterior cingulate cortex, as well as prefrontal areas involved in the cognitive regulation of emotions, and enhancing the coupling of limbic and prefrontal areas. Oxytocin as a promising pharmacological approach to emotion dysregulation in BPD was shown to dampen amygdala activity in response to emotional stimuli. Understanding the brain mechanisms that mediate treatment effects will harness further development of targeted mechanism-based interventions for patients with BPD.