The neurobiology of empathy in borderline personality disorder

Early affective empathy, emotion contagion, and empathic concern in borderline personality disorder: A systematic review and meta-analysis

BACKGROUND

Individuals with Borderline Personality Disorder (BPD) are theorized to experience lower cognitive empathy but heightened affective empathy. Despite meta-analyses addressing cognitive empathy, affective empathy remains unexplored. This pre-registered systematic review and meta-analysis investigated affective empathy in individuals with BPD or high BPD traits relative to healthy comparisons, using a multidimensional approach including, early affective empathy, emotion contagion, and empathic concern.

METHODS

Systematic search of SCOPUS, PubMed, Medline COMPLETE, and PsycINFO (June 27, 2022, May 14, 2023, and July 1, 2024) was completed. Included studies compared affective empathy in those with BPD/high BPD traits with healthy comparisons, utilized experimental or self-report designs, and were peer-reviewed or PhD theses. Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Among 22 eligible studies identified, results revealed individuals with BPD/high BPD traits showed significantly higher emotion contagion (Npooled = 1797, g = -1.10, 95 % CI [-1.57, -0.62]). No significant differences were found in empathic concern (Npooled = 1545, g = 0.06, 95 % CI [-0.10, 0.22]), or early affective empathy for anger (Npooled = 245, g = 0.28, 95 % CI [-0.0.53, 1.09]) and happiness, (Npooled = 189, g = 0.34, 95 % CI [-0.1.50, 2.18]).

LIMITATIONS

Few included studies for early affective empathy, methodological shortcomings in the broader literature and study heterogeneity suggest caution when interpreting these effects, emphasizing the need for targeted research.

CONCLUSIONS

While individuals with BPD/high BPD traits are more likely to subjectively experience others' distress through emotion contagion, no differences were found in early affective empathy or ability to direct sympathy and concern towards others.

The dark side of personality functioning: associations between antisocial cognitions, personality functioning (AMPD), empathy and mentalisation

Introduction

With the introduction of the new psychiatric diagnostic manuals, personality functioning has gained new prominence. Several studies have reported consistent findings that individual showing high levels of antisocial features are associated with alterations in interpersonal functioning domains such as empathy and mentalisation. The focus of the current study (N = 198) is to examine antisocial cognitions, as measured by the Scrambled Sentences Task (SST), and to what extent this approach can help to better understand the relationship between antisocial traits and personality functioning/empathy.

Method

We implemented a hypothesis-driven approach using logistic regression and a data-driven approach using machine learning to examine distinct but related measures of personality functioning as predictors of antisocial cognitions.

Results

Antisocial cognitions were associated with low interpersonal functioning as expected, but only when not adjusting for antisocial traits, which accounted for almost all the association. The data-driven analysis revealed that individual items assessing empathic concern in personality functioning scales (as opposed to the whole scores) explained low antisocial cognitions even when adjusting for antisocial traits.

Discussion

Antisocial cognitions appear to be associated to two distinct traits, the antisocial and a specific type of personality functioning. This finding is discussed in terms of the possible distinction between two motivational forces: to harm others/prioritize one's advantage, and to help suffering others.

Brain Activation for Social Cognition and Emotion Processing Tasks in Borderline Personality Disorder: A Meta-Analysis of Neuroimaging Studies

The present meta-analysis summarizes brain activation for social cognition and emotion-processing tasks in borderline personality disorder (BPD). We carried out two meta-analyses to elaborate on commonalities and potential differences between the two types of tasks. In the first meta-analysis, we implemented a more liberal strategy for task selection (including social and emotional content). The results confirmed previously reported hyperactivations in patients with BPD in the bilateral amygdala and prefrontal cortex and hypoactivations in bilateral inferior frontal gyri. When applying a stricter approach to task selection, focusing narrowly on social cognition tasks, we only found activation in prefrontal areas, particularly in the anterior cingulate and ventromedial prefrontal cortex. We review the role of these areas in social cognition in healthy adults, suggesting that the observed BPD hyperactivations may reflect an overreliance on self-related thought in social cognition.

Mentalizing in Adolescents with Borderline Personality Disorder

Mentalizing, recognized as the capacity to understand behaviors in the context of our own mental states and those of other people, is being researched more and more commonly in regard to various mental disorders. The research on mentalization focuses on, among other things, borderline personality disorder, which is at present perceived as an emerging problem in the population of adolescents. In order to summarize the currently accessible knowledge of mentalizing in adolescents with borderline personality disorder, we thoroughly analyzed relevant publications. Based on the available literature, it can be concluded that the mentalizing ability of adolescents with borderline personality disorder can be impaired. The evidence demonstrates that they are prone to hypermentalizing, defined as an overattribution of mental states to other people. However, this tendency has not been proven to be specific to teenagers with this disorder. Moreover, the existing data suggest that young people with borderline personality exhibit a reduced capacity to mentalize their own inner states.

Social affective behaviors among female rats involve the basolateral amygdala and insular cortex

The ability to detect, appraise, and respond to another's emotional state is essential to social affective behavior. This is mediated by a network of brain regions responsible for integrating external cues with internal states to orchestrate situationally appropriate behavioral responses. The basolateral amygdala (BLA) and the insular cortex are reciprocally connected regions involved in social cognition and prior work in male rats revealed their contributions to social affective behavior. We investigated the functional role of these regions in female rats in a social affective preference (SAP) test in which experimental rats approach stressed juvenile but avoid stressed adult conspecifics. In separate experiments, the BLA or the insula were inhibited by local infusion of muscimol (100ng/side in 0.5μL saline) or vehicle prior to SAP tests. In both regions, muscimol interfered with preference for the stressed juvenile and naive adult, indicating that these regions are necessary for appropriate social affective behavior. In male rats, SAP behavior requires insular oxytocin but there are noteworthy sex differences in the oxytocin receptor distribution in rats. Oxytocin (500nM) administered to the insula did not alter social behavior but oxytocin infusions to the BLA increased social interaction. In sum, female rats appear to use the same BLA and insula regions for social affective behavior but sex differences exist in contribution of oxytocin in the insula.

Maternal Variability of Amplitudes of Frequency Fluctuations Is Related to the Progressive Self-Other Transposition Group Intervention in Autistic Children

The self-to-other model of empathy (SOME) states that a key reason for the empathic deficiency in autistic individuals is the imbalance of the self-other switch. The existing interventions of theory of mind contain training of self-other transposition ability but combined with other cognitive trainings. The self-other distinction brain areas of autistic individuals have been revealed, but the brain areas of the self-other transposition ability and its intervention have not been investigated. There are normalized amplitudes of low-frequency fluctuations (mALFFs) within 0.01-0.1 Hz and many normalized amplitudes of frequency fluctuations (mAFFs) within 0-0.01, 0.01-0.05, 0.05-0.1, 0.1-0.15, 0.15-0.2, and 0.2-0.25 Hz. Therefore, the current study established a progressive self-other transposition group intervention to specifically and systematically improve autistic children's self-other transposition abilities. The transposition test with a three mountains test, an unexpected location test, and a deception test was used to directly measure autistic children's transposition abilities. The Interpersonal Responsiveness Index Empathy Questionnaire with perspective-taking and fantasy subscales (IRI-T) was used to indirectly measure autistic children's transposition abilities. The Autism Treatment Evaluation Checklist (ATEC) was used to measure autistic children's autism symptoms. The experiment was designed with two (intervention: experimental group vs. control group) independent variables and two (test time: pretest vs. posttest or tracking test) × three (test: transposition test vs. IRI-T test vs. ATEC test) dependent variables. Furthermore, it used eyes-closed resting-state functional magnetic resonance imaging to investigate and compare the relevant maternal mALFFs and average energy rank and energy rank variability of mAFFs of autistic children's transposition abilities, autism symptoms, and intervention effects. The results showed the following: (1) There were many improvements (pretest vs. posttest or tracking test) greater than chance 0 in the experimental group, such as the three mountains, lie, transposition, PT, IRI-T, PT tracking, cognition, behavior, ATEC, language tracking, cognition tracking, behavior tracking, and ATEC tracking improvements. However, there was no improvement greater than chance 0 in the control group. (2) The maternal mALFFs and maternal average energy rank and energy rank variability of mAFFs could predict the autistic children's transposition abilities, autism symptoms, and intervention effects with some overlap and some difference in maternal self-other distinction, sensorimotor, visual, facial expression recognition, language, memory and emotion, and self-consciousness networks. These results indicated that the progressive self-other transposition group intervention successfully improved autistic children's transposition abilities and reduced their autism symptoms; the intervention effects could be applied to daily life and last up to a month. The maternal mALFFs, average energy rank, and energy rank variability of mAFFs were three effective neural indictors of autistic children's transposition abilities, autism symptoms, and intervention effects, and the average energy rank and energy rank variability of mAFFs were two new neural indictors established in the current study. The maternal neural markers of the progressive self-other transposition group intervention effects for autistic children were found in part.

Social affective behaviors among female rats involve the basolateral amygdala and insular cortex

The ability to detect, appraise, and respond to another's emotional state is essential to social affective behavior. This is mediated by a network of brain regions responsible for integrating external cues with internal states to orchestrate situationally appropriate behavioral responses. The basolateral amygdala (BLA) and the insular cortex are reciprocally connected regions involved in social cognition and prior work in male rats revealed their contributions to social affective behavior. We investigated the functional role of these regions in female rats in a social affective preference (SAP) test in which experimental rats approach stressed juvenile but avoid stressed adult conspecifics. In separate experiments, the BLA or the insula were inhibited by local infusion of muscimol (100ng/side in 0.5μL saline) or vehicle prior to SAP tests. In both regions, muscimol interfered with preference for the stressed juvenile and naive adult, indicating that these regions are necessary for appropriate social affective behavior. In male rats, SAP behavior requires insular oxytocin but there are noteworthy sex differences in the oxytocin receptor distribution in rats. Oxytocin (500nM) administered to the insula did not alter social behavior but oxytocin infusions to the BLA increased social interaction. In sum, female rats appear to use the same BLA and insula regions for social affective behavior but sex differences exist in contribution of oxytocin in the insula.

The gradient model of brain organization in decisions involving “empathy for pain”

Influential models of cortical organization propose a close relationship between heteromodal association areas and highly connected hubs in the default mode network. The “gradient model” of cortical organization proposes a close relationship between these areas and highly connected hubs in the default mode network, a set of cortical areas deactivated by demanding tasks. Here, we used a decision-making task and representational similarity analysis with classic “empathy for pain” stimuli to probe the relationship between high-level representations of imminent pain in others and these areas. High-level representations were colocalized with task deactivations or the transitions from activations to deactivations. These loci belonged to 2 groups: those that loaded on the high end of the principal cortical gradient and were associated by meta-analytic decoding with the default mode network, and those that appeared to accompany functional repurposing of somatosensory cortex in the presence of visual stimuli. These findings suggest that task deactivations may set out cortical areas that host high-level representations. We anticipate that an increased understanding of the cortical correlates of high-level representations may improve neurobiological models of social interactions and psychopathology.

A Short Functional Neuroimaging Assay Using Attachment Scenes to Recruit Neural Correlates of Social Cognition—A Replication Study

Attachment theory provides a conceptual framework to understand the impact of early child–caregiver experiences, such as loss or separation, on adult functioning and psychopathology. In the current study, scenes from the Adult Attachment Projective Picture System (AAP), a validated, commonly used standardized diagnostic instrument to assess adult attachment representations, were used to develop a short fMRI assay eliciting the neural correlates of encoding of potentially hurtful and threatening social situations such as social losses, rejections or loneliness. Data from healthy participants (N = 19) showed activations in brain areas associated with social cognition and semantic knowledge during exposure to attachment-related scenes compared to control scenes. Extensive activation of the temporal poles was observed, suggesting the use of semantic knowledge for generating social concepts and scripts. This knowledge may underlie our ability to explain and predict social interactions, a specific aspect of theory of mind or mentalization. In this replication study, we verified the effectiveness of a modified fMRI assay to assess the external validity of a previously used imaging paradigm to investigate the processing of emotionally negatively valenced and painful social interactions. Our data confirm the recruitment of brain areas associated with social cognition with our very short neuroimaging assay.

Animal Abuse as an Indicator of Domestic Violence: One Health, One Welfare Approach

For years now, the importance of animal cruelty has been gaining recognition in the industrialized cities of the West. Animal cruelty encompasses any act that causes a non-human animal unnecessary pain or suffering, including negligence, abandonment, abuse, torture, bestiality, and even theriocide. This represents a red flag for society as a whole because people who commit such acts can escalate violence and direct it to other individuals. Animal cruelty and interpersonal violence—as well as other socially undesirable conduct such as bullying, antisocial personality disorder, rape, and serial murder—are closely related, so timely diagnoses of either one can help prevent acts of aggression. It is necessary, therefore, to analyze and try to understand whether there are early indicators that may help identify potentially violent individuals. It is well known that kids from homes with actual violence in their homes show a high tendency to reproduce such behaviors with both animals and other people. In conclusion, much research and rethinking of the importance of the veterinarian in detecting animal abuse and cruelty is needed to help detect and prevent cases of interpersonal violence that may arise over time.

The role of impairments in self-other distinction in borderline personality disorder: A narrative review of recent evidence

Impairments in maintaining a differentiated sense of "self" and "other" are thought to be a central feature of borderline personality disorder (BPD). However, studies directly focusing on self-other distinction (SOD) in BPD are scarce, and these findings have not yet been integrated with novel insights into the neural mechanism involved in SOD. Here, we present a narrative review of recent behavioral and neuroimaging findings focusing on impairments in SOD in BPD. Behavioral findings of SOD at the embodied level provide preliminary evidence for impairments in multisensory integration in BPD. Furthermore, both behavioral and neuroscientific data converge to suggest that SOD impairments in BPD reflect an inability to shift between self and other representations according to task demands. Research also suggests that disruptions in infant-caregiver synchrony may play a role in the development of these impairments. Based on these findings, we present a new, integrative model linking impairments in SOD to reduced neural and behavioral synchrony in BPD. The implications of these findings for future research and clinical interventions are outlined.

Facial Emotion Perception in Borderline Personality Disorder: Differential Neural Activation to Ambiguous and Threatening Expressions and Links to Impairments in Self and Interpersonal Functioning

BACKGROUND

Many individuals with borderline personality disorder (BPD) perceive emotional expressions in faces intended to convey no emotion and display a heightened sensitivity to facial expressions conveying threat, such as fear. In BPD, the amygdala activates in response to ambiguous and threatening facial expressions, although the differential sensitivity of this brain region to higher and lower intensities of fearful expressions and the relationship of this neural activity to personality impairments have not yet been investigated.

METHODS

In the present study, we examined brain activation during an implicit facial emotion task with neutral faces and fearful expressions displayed at 50% and 100% intensity in patients with BPD (n=45) and healthy controls (HC; n=25).

RESULTS

On neutral faces, higher brain activation was found in BPD compared to HC in the right temporal pole, amygdala, hippocampus, pallidum, and orbitofrontal cortex, whereas no significant whole-brain group differences were observed for either intensity of fearful expressions. A region-of-interest analysis focused on the amygdala-hippocampal complex showed greater activation for neutral and 50%-intensity fearful faces in BPD. Severity of personality impairment in the domains of empathy and identity were associated with higher precuneus activity during neutral and 100%-fearful face processing.

LIMITATIONS

Brain activation differences of this naturalistic severely ill inpatient sample may be influenced by comorbid Axis-I disorders often seen in samples of BPD.

CONCLUSIONS

These findings suggest a heightened amygdala-hippocampal response to neutral faces and moderate-intensity fearful expressions in BPD, while self and interpersonal impairments are associated with task-based activations in regions implicated in self-referential processes.

The Mentalizing Approach to Psychopathology: State of the Art and Future Directions

Mentalizing is the capacity to understand others and oneself in terms of internal mental states. It is assumed to be underpinned by four dimensions: automatic–controlled, internally–externally focused, self–other, and cognitive–affective. Research suggests that mental disorders are associated with different imbalances in these dimensions. Addressing the quality of mentalizing as part of psychosocial treatments may benefit individuals with various mental disorders. We suggest that mentalizing is a helpful transtheoretical and transdiagnostic concept to explain vulnerability to psychopathology and its treatment. This review summarizes the mentalizing approach to psychopathology from a developmental socioecological evolutionary perspective. We then focus on the application of the mentalizing approach to personality disorders, and we review studies that have extended this approach to other types of psychopathology, including depression, anxiety, and eating disorders. We summarize core principles of mentalization-based treatments and preventive interventions and the evidence for their effectiveness. We conclude with recommendations for future research.

Dysfunction of Empathy and Related Processes in Borderline Personality Disorder: A Systematic Review

After participating in this activity, learners should be better able to:• Assess differences between adult patients with the diagnosis of borderline personality disorder (BPD) and healthy control subjects in terms of empathy and related processes• Evaluate the effects of empathy or related processes as factors contributing to abnormal social functioning in BPD ABSTRACT: We reviewed 45 original research studies, published between 2000 and 2019, to assess differences between adult patients with the diagnosis of borderline personality disorder (BPD) and healthy control subjects in terms of empathy and related processes (i.e., theory of mind, mentalizing, social cognition, and emotional intelligence). Thirty-six studies reported deficits of empathy or related processes in patients with BPD. Enhanced emotional empathy in BPD was also reported in eight studies, all of which revealed that patients had increased scores of personal distress on the Interpersonal Reactivity Index self-report questionnaire. Six studies did not find significant differences between patients with BPD and healthy control subjects in terms of empathy or related processes. No study reported enhanced cognitive empathy, social cognition, or emotional intelligence in patients with BPD. We postulate that deficits of empathy or related processes contribute to preempting the formation of stable interpersonal relationships, whereas enhanced emotional empathy might lead to personal (and interpersonal) distress, further contributing to abnormal social functioning in BPD.

Assessing self-reported empathy and altruism in patients suffering from enduring borderline personality disorder

Self-report studies on empathy in adults with borderline personality disorder (BPD) have based upon the Interpersonal Reactivity Index (IRI) and generally identified deficits in perspective taking abilities in this group, but indicated less coherent results regarding empathic concern. These two constructs are considered subcomponents of cognitive (CE) and affective empathy (AE), respectively. However, the IRI does not enable for valid investigation of overall levels of these empathy types. Surprisingly, although some findings from the general population suggest that empathy types may be positively related to altruism, neither this link nor general altruism have been examined in BPD. Additionally, these constructs have not been sufficiently studied in this group in the context of alexithymia or potential clinical confounders. Hence, women with BPD (N = 30) and healthy women (N = 38) completed, i.a., the Questionnaire of Cognitive and Affective Empathy, Self-Report Altruism Scale, TAS-20, STAI, and CESD-R. Patients with BPD reported significantly decreased overall CE (including worse online simulation abilities - conceptually similar to perspective taking from the IRI), but a similar level of overall AE. They also demonstrated lower altruism. Taken together, these results suggest that BPD patients have difficulties with imagining what emotions others are feeling and with altruistic responding to their needs.

Mirror neuron activations in encoding of psychic pain in borderline personality disorder

Borderline personality disorder (BPD) is characterized by pronounced emotional instability in interpersonal relations. Previous studies have shown increased activity in the amygdala, an imaging phenotype of negative affect. However, clinical accounts of BPD have drawn attention to deficits in social cognition and their likely role in engendering emotional instability. BPD patients show enhanced sensitivity to other people's emotions, while being less proficient in reading motives and reasons. In the present functional imaging study, we exposed BPD participants to stylized scenes of individuals affected by loss or separation, an issue to which these patients are particularly sensitive. Previously shown to activate the mirror neuron system, these mourning scenes were here also used to assess differential amygdala activity in stimuli of negative valence, but low arousal. Relative to controls, BPD patients were found to activate sensorimotor areas, a part of the mirror neuron system thought to encode basic aspects of the perception of motoric activity and pain. This contrasted with the activity of areas related to more complex aspects of social cognition, such as the inferior frontal gyrus. The amygdala was more active in patients when viewing these scenes, but this effect also showed a strong association with levels of depressiveness and neuroticism. After adjusting for these covariates, differences in amygdala activation were no longer significant. These findings are consistent with models of social cognition in BPD that attribute emotional sensitivity to emotional contagion through the mirror neuron system, in contrast to areas associated with more sophisticated forms of social cognition. These effects were accompanied by increased amygdala reactivity, consistently with the common occurrence of affective symptoms in these patients.

Psychophysiological Reactivity Profiles of Partner-Violent Men With Borderline or Psychopathic Personality Features: The Role of Empathy

Borderline and psychopathic features have been linked to unique psychophysiological reactivity profiles. Studies have suggested that levels of psychophysiological reactivity for partner-violent men cannot be attributed to personality features alone. This study tested cognitive and affective empathy as moderators of relations between borderline personality, Factor 1 psychopathy, and psychophysiological reactivity using a community sample of 135 male participants and their female partners. Cognitive empathy moderated the relation between borderline personality features and heart rate reactivity. Affective empathy moderated the relation between Factor 1 psychopathy features and heart rate reactivity. However, directions of these interactions were contrary to original predictions. Understanding unique empathy deficits may be beneficial for identifying ways to minimize relationship conflict, manage arousal, and decrease violence.

A Neural Model of Empathic States in Attachment-Based Psychotherapy

We build on a neuroanatomical model of how empathic states can motivate caregiving behavior, via empathy circuit-driven activation of regions in the hypothalamus and amygdala, which in turn stimulate a mesolimbic-ventral pallidum pathway, by integrating findings related to the perception of pain in self and others. On this basis, we propose a network to capture states of personal distress and (weak and strong forms of) empathic concern, which are particularly relevant for psychotherapists conducting attachment-based interventions. This model is then extended for the case of self-attachment therapy, in which conceptualized components of the self serve as both the source of and target for empathic resonance. In particular, we consider how states of empathic concern involving an other that is perceived as being closely related to the self might enhance the motivation for self-directed bonding (which in turn is proposed to lead the individual toward more compassionate states) in terms of medial prefrontal cortex-mediated activation of these caregiving pathways. We simulate our model computationally and discuss the interplay between the bonding and empathy protocols of the therapy.

Neurobiology of Criterion A: self and interpersonal personality functioning

The Criterion A of the DSM-5 Alternative Model of Personality Disorders follows a functional approach to personality disorders which can be effectively related to abnormalities in brain circuits that are involved in processes related to the self and others. While brain circuits related to the self and others highly overlap supporting the notion of inseparable constructs, structural and functional neuroimaging data point to rather specific deviations in brain processes among the various types of personality disorders, with a focus on borderline and antisocial personality disorders. Neurobiological data have shed light on the problem areas of individuals with personality disorders that goes beyond what we know from either patients' reports or observing their behavior and may open new perspectives on treatment.

Conduct problems in youth and the RDoC approach: A developmental, evolutionary-based view

Problems related to aggression in young people are traditionally subsumed under the header of conduct problems, which include conduct disorder and oppositional defiant disorder. Such problems in children and adolescents are an important societal and mental health problem. In this paper we present an evolutionarily informed developmental psychopathology view of conduct problems inspired by the NIMH Research Domain Criteria (RDoC) initiative. We assume that while there are many pathways to conduct problems, chronic or temporary impairments in the domain of social cognition or mentalizing are a common denominator. Specifically, we conceptualize conduct problems as reflecting temporary or chronic difficulties with mentalizing, that is, the capacity to understand the self and others in terms of intentional mental states, leading to a failure to inhibit interpersonal violence through a process of perspective-taking and empathy. These difficulties, in turn, stem from impairments in making use of a normally evolutionarily protected social learning system that functions to facilitate intergenerational knowledge transmission and protect social collaborative processes from impulsive and aggressive action. Temperamental, biological, and social risk factors in different combinations may all contribute to this outcome. This adaptation then interacts with impairments in other domains of functioning, such as in negative and positive valence systems and cognitive systems. This view highlights the importance of a complex interplay among biological, psychological, and environmental factors in understanding the origins of conduct problems. We outline the implications of these views for future research and intervention.

What we have changed our minds about: Part 1. Borderline personality disorder as a limitation of resilience

This paper sets out a recent transition in our thinking in relation to psychopathology associated with personality disorder, in an approach that integrates our thinking about attachment, mentalizing (understanding ourselves and others in terms of intentional mental states) and epistemic trust (openness to the reception of social communication that is personally relevant and of generalizable significance) with recent findings on the structure of both adult and child psychopathology and resilience. In this paper - the first of two parts - we review evidence suggesting that a general psychopathology or p factor underlies vulnerability for psychopathology. We link this p factor to a lack of resilience using Kalisch and colleagues' positive appraisal style theory of resilience (PASTOR). We argue that vulnerability for (severe) psychopathology results from impairments in three central mechanisms underlying resilience - positive situation classification, retrospective reappraisal of threat, and inhibition of retraumatizing triggers - which in turn result from a lack of flexibility in terms of social communicative processes. We suggest that, from this perspective, personality disorders, and borderline personality disorder (BPD) in particular, can be considered to be the prototype of disorders characterized by a lack of resilience. Part 2 proposes an evolutionary developmental psychopathology account linking this inflexibility in social communication to problems with the development of epistemic trust - that is, an evolutionary pre-wired social communication system that normally facilitates resilience through salutogenesis, that is, the capacity to learn and derive benefit from the (social) environment.

Rationality and self-interest as economic-exchange strategy in borderline personality disorder: Game theory, social preferences, and interpersonal behavior

Borderline Personality Disorder (BPD) is characterized by severe and persistent impairments in interpersonal functioning. Given the complexity of social interactions, studying the interactive behavior of BPD patients is challenging. One way to implement both tight experimental control and realistic, externally valid settings is to use game-theoretical experiments. This review discusses findings from economic exchange studies in BPD against the background of game-theoretical literature. BPD patients do not seem to derive utility from mutual cooperation with others and appear not to "forgive" a partner's unfairness. By pursuing a strategy of negative reciprocity, BPD patients seem to act mostly "rationally" and in their own self-interest. Their "grim trigger strategy" resembles the theoretical ideal of the rational and self-interested agent homo economicus. Finally, we summarize how research findings from economics and clinical psychiatry may be mutually enriching and propose new research ideas in this fascinating field.

Self-other disturbance in borderline personality disorder: Neural, self-report, and performance-based evidence

Individuals with borderline personality disorder (BPD) display an impoverished sense of self and representations of self and others that shift between positive and negative poles. However, little research has investigated the nature of representational disturbance in BPD. The present study takes a multimodal approach. A card sort task was used to investigate complexity, integration, and valence of self-representation in BPD. Impairment in maintenance of self and other representations was assessed using a personality representational maintenance task. Finally, functional MRI (fMRI) was used to assess whether individuals with BPD show neural abnormalities related specifically to the self and what brain areas may be related to poor representational maintenance. Individuals with BPD sorted self-aspects suggesting more complexity of self-representation, but also less integration and more negative valence overall. On the representational maintenance task, individuals with BPD showed less consistency in their representations of self and others over the 3-hr period, but only for abstract, personality-based representations. Performance on this measure mediated between-groups brain activation in several areas supporting social cognition. We found no evidence for social-cognitive disturbance specific to the self. Additionally, the BPD group showed main effects, insensitive to condition, of hyperactivation in the medial prefrontal cortex, temporal parietal junction, several regions of the frontal pole, the precuneus and middle temporal gyrus, all areas crucial social cognition. In contrast, controls evidenced greater activation in visual, sensory, motor, and mirror neuron regions. These findings are discussed in relation to research regarding hypermentalization and the overlap between self- and other-disturbance.

Thyroid hormones and adult interpersonal violence among women with borderline personality disorder

Elevated T3 levels have been reported in men with antisocial behavior. The aim of the present study was to investigate the relationship between thyroid hormones and expressed adult interpersonal violence in female patients with borderline personality disorder (BPD). Furthermore, expressed adult interpersonal violence in female BPD patients was compared to healthy female controls. A total of 92 clinically euthyroid women with BPD and 57 healthy women were assessed with the Karolinska Interpersonal Violence Scales (KIVS). Baseline thyroid function was evaluated by measuring plasma free and bound triiodothyronine (FT3 and T3), thyroxine (FT4 and T4), and thyroid-stimulating hormone (TSH) with immunoassays in patients. Plasma cortisol was also measured. Among females with BPD, expressed interpersonal violence as an adult showed a significant positive correlation with the T3 levels. The mean expression of interpersonal violence as an adult was significantly higher in BPD patients as compared to healthy controls. The multiple regression model indicated that two independent predictors of KIVS expressed interpersonal violence as an adult: T3 and comorbid diagnosis of alcohol abuse. Association between T3 levels and violent/aggressive behavior earlier reported exclusively in male samples may be valid also in females with BPD.

Toward a radically embodied neuroscience of attachment and relationships

Attachment theory (Bowlby, 1969/1982) posits the existence of internal working models as a foundational feature of human bonds. Radical embodied approaches instead suggest that cognition requires no computation or representation, favoring a cognition situated in a body in an environmental context with affordances for action (Chemero, 2009; Barrett, 2011; Wilson and Golonka, 2013; Casasanto and Lupyan, 2015). We explore whether embodied approaches to social soothing, interpersonal warmth, separation distress, and support seeking could replace representational constructs such as internal working models with a view of relationship cognition anchored in the resources afforded to the individual by their brain, body, and environment in interaction. We review the neurobiological bases for social attachments and relationships and attempt to delineate how these systems overlap or don’t with more basic physiological systems in ways that support or contradict a radical embodied explanation. We suggest that many effects might be the result of the fact that relationship cognition depends on and emerges out of the action of neural systems that regulate several clearly physically grounded systems. For example, the neuropeptide oxytocin appears to be central to attachment and pair-bond behavior (Carter and Keverne, 2002) and is implicated in social thermoregulation more broadly, being necessary for maintaining a warm body temperature (for a review, see IJzerman et al., 2015b). Finally, we discuss the most challenging issues around taking a radically embodied perspective on social relationships. We find the most crucial challenge in individual differences in support seeking and responses to social contact, which have long been thought to be a function of representational structures in the mind (e.g., Baldwin, 1995). Together we entertain the thought to explain such individual differences without mediating representations or computations, but in the end propose a hybrid model of radical embodiment and internal representations.

Some markers of mirroring appear intact in schizophrenia: evidence from mu suppression

Although schizophrenia is associated with impairments in social cognition, the scope and neural correlates of these disturbances are largely unknown. In this study, we investigated whether schizophrenia patients show impaired functioning of the mirror neuron system (MNS), as indexed by electroencephalographic (EEG) mu (8-13 Hz) suppression, a hypothesized biomarker of MNS activity that is sensitive to the degree of social interaction depicted in visual stimuli. A total of 32 outpatients and 26 healthy controls completed an EEG paradigm that included six action observation or execution conditions that differed in their degrees of social interaction. Participants also completed a validated empathy questionnaire. Across both groups, we found a significant linear increase in mu suppression across the conditions involving greater levels of social engagement and interaction, but no significant group or interaction effects. Patients self-reported diminished empathic concern and perspective taking, which showed some moderate relations to mu suppression levels. Thus, the schizophrenia group showed generally intact modulation of MNS functioning at the electrophysiological level, despite self-reporting empathic disturbances. The disturbances commonly seen on self-report, performance, and neuroimaging measures of mentalizing in schizophrenia may largely reflect difficulties with higher-level inferential processes about others' emotions, rather than a basic incapacity to share in these experiences.

Automatic processing of facial affects in patients with borderline personality disorder: associations with symptomatology and comorbid disorders

BACKGROUND

Instability of affects and interpersonal relations are important features of borderline personality disorder (BPD). Interpersonal problems of individuals suffering from BPD might develop based on abnormalities in the processing of facial affects and high sensitivity to negative affective expressions. The aims of the present study were to examine automatic evaluative shifts and latencies as a function of masked facial affects in patients with BPD compared to healthy individuals. As BPD comorbidity rates for mental and personality disorders are high, we investigated also the relationships of affective processing characteristics with specific borderline symptoms and comorbidity.

METHODS

Twenty-nine women with BPD and 38 healthy women participated in the study. The majority of patients suffered from additional Axis I disorders and/or additional personality disorders. In the priming experiment, angry, happy, neutral, or no facial expression was briefly presented (for 33 ms) and masked by neutral faces that had to be evaluated. Evaluative decisions and response latencies were registered. Borderline-typical symptomatology was assessed with the Borderline Symptom List.

RESULTS

In the total sample, valence-congruent evaluative shifts and delays of evaluative decision due to facial affect were observed. No between-group differences were obtained for evaluative decisions and latencies. The presence of comorbid anxiety disorders was found to be positively correlated with evaluative shifting owing to masked happy primes, regardless of baseline-neutral or no facial expression condition. The presence of comorbid depressive disorder, paranoid personality disorder, and symptoms of social isolation and self-aggression were significantly correlated with response delay due to masked angry faces, regardless of baseline.

CONCLUSIONS

In the present affective priming study, no abnormalities in the automatic recognition and processing of facial affects were observed in BPD patients compared to healthy individuals. The presence of comorbid anxiety disorders could make patients more susceptible to the influence of a happy expression on judgment processes at an automatic processing level. Comorbid depressive disorder, paranoid personality disorder, and symptoms of social isolation and self-aggression may enhance automatic attention allocation to threatening facial expressions in BPD. Increased automatic vigilance for social threat stimuli might contribute to affective instability and interpersonal problems in specific patients with BPD.

Enhanced emotional empathy after mineralocorticoid receptor stimulation in women with borderline personality disorder and healthy women

The mineralocorticoid receptor (MR) is highly expressed in the hippocampus and prefrontal cortex. MR have an important role in appraisal processes and in modulating stress-associated emotional reactions but it is not known whether the MR affects empathy. Borderline personality disorder (BPD) is characterized by disturbed emotion regulation and alterations in empathy. In the current study, we examined whether stimulation of the MR enhances empathy in patients with BPD and healthy individuals. In a placebo-controlled study, we randomized 38 women with BPD and without psychotropic medication, and 35 healthy women to either placebo or 0.4 mg fludrocortisone, an MR agonist. Subsequently, all participants underwent two tests of social cognition, the Multifaceted Empathy Test (MET) and the Movie for the Assessment of Social Cognition (MASC), measuring cognitive and emotional facets of empathy. Eighteen BPD patients and 18 healthy women received placebo, whereas 20 BPD patients and 17 healthy women received fludrocortisone. In the MET, fludrocortisone enhanced emotional empathy across groups, whereas cognitive empathy was not affected. In the MASC, no effect of fludrocortisone could be revealed. In both tests, BPD patients and healthy women did not differ significantly in cognitive and emotional empathy and in their response to fludrocortisone. Stimulation of MR enhanced emotional empathy in healthy women and in BPD patients. Whether fludrocortisone might have a therapeutic role in psychotherapeutic processes, remains to be elucidated.

Physical and social pains in borderline disorder and neuroanatomical correlates: a systematic review

Borderline personality disorder (BPD) is a common psychiatric disorder, the core features of which are affective dysregulation, identity disturbances, and problems in social interaction, with an intense fear of loss, abandonment, or rejection by social partners. Self-injurious behaviors (SIB), such as superficial cutting, occur in 70-80 % of BPD patients, which are associated with emotional relief. Intriguingly, the majority of BPD patients report reduced or no pain associated with SIB, whereas BPD patients are over-represented in chronic pain patients. Thus, studying pain perception in such patients may help to understand the pathophysiology of BPD, but also the interaction between affective and physical dimensions of pain. We conducted a systematic review dealing with physical and social pains in BPD patients, with a special focus on neuroimaging data. SIB appear to be an inadequate strategy to regulate negative emotions that may be related to social/psychological pain, by increasing dorsolateral prefrontal cortex activation in order to regulate amygdala activation. In addition, abnormal hyperactivation of the insula is a possible trait marker of BPD, and might contribute to modified pain sensitivity. When considering psychological pain in BPD patients, neuroanatomical studies have shown a hyper-responsive subcortical limbic network and a deficient regulatory control system operating through anterior brain regions. Promising therapeutic strategies should target neuroanatomical and neurobiological dysfunctions, which lead to altered pain perception in BPD patients.

Empathy in narcissistic personality disorder: from clinical and empirical perspectives

Narcissistic personality disorder (NPD) is associated with an assortment of characteristics that undermine interpersonal functioning. A lack of empathy is often cited as the primary distinguishing feature of NPD. However, clinical presentations of NPD suggest that empathy is not simply deficient in these individuals, but dysfunctional and subject to a diverse set of motivational and situational factors. Consistent with this presentation, research illustrates that empathy is multidimensional, involving 2 distinct emotional and cognitive processes associated with a capacity to respectively understand and respond to others' mental and affective states. The goal of this practice review is to bridge the gap between our psychobiological understanding of empathy and its clinical manifestations in NPD. We present 3 case studies highlighting the variability in empathic functioning in people with NPD. Additionally, we summarize the literature on empathy and NPD, which largely associates this disorder with deficient emotional empathy, and dysfunctional rather than deficient cognitive empathy. Because this research is limited, we also present empathy-based findings for related syndromes (borderline and psychopathy). Given the complexity of narcissism and empathy, we propose that multiple relationships can exist between these constructs. Ultimately, by recognizing the multifaceted relationship between empathy and narcissism, and moving away from an all or nothing belief that those with NPD simply lack empathy, therapists may better understand narcissistic patients' behavior and motivational structure.

Personality disorders, attachment and psychodynamic psychotherapy

While attachment has been a fruitful and critical concept in understanding enduring individual templates for interpersonal relationships, it does not have a well-understood relationship to personality disorders, where impairment of interpersonal functioning is paramount. Despite the recognition that attachment disturbances do not simply reflect nonoptimal caretaking environments, the relationship of underlying temperamental factors to these environmental insults has not been fully explored. In this paper we provide an alternate model for the role of neurobiological temperamental factors, including brain circuitry and neuropeptide modulation, in mediating social cognition and the internalization and maintenance of attachment patterns. The implications of these altered attachment patterns on personality disorders and their neurobiological and environmental roots for psychoanalytically based treatment models designed to ameliorate difficulties in interpersonal functioning through the medium of increased access to mature forms of mentalization is discussed.