The broken trust and cooperation in borderline personality disorder

A Model of Trust Processes in Borderline Personality Disorder: A Systematic Review

PURPOSE OF REVIEW

Unstable relationships are a core feature of borderline personality disorder (BPD). Impairments in trust processes (i.e., appraisal and learning regarding others' trustworthiness) can subserve interpersonal problems associated with BPD, but the determinants, mechanisms, consequences, and variations in trust impairments among individuals with BPD remain poorly characterized. Thus, a better understanding of such impairments could help target interventions that address the interpersonal problems of individuals with BPD beyond emotion dysregulation, impulsivity, and aggression.

RECENT FINDINGS

We conducted a pre-registered systematic review of empirical studies on trust processes and BPD features (k = 29). Results are organized around a heuristic model of trust processes in BPD comprising the following stages: developmental factors, prior beliefs and dispositions, situation perception, emotional states, trust appraisal, behavioral manifestations, and trust learning. Based on the synthesis of the findings, we recommended directions for future research and clinical assessment and intervention, such as managing trust during the early stages of therapy and considering improvements in trust processes as a central mechanism of change in treating individuals with BPD.

Atypical Neural Plasticity and Behavioral Effects of Trustworthiness Learning in Borderline Personality Disorder Features

This study distinguishes interpersonal trust learning with a novel trust learning paradigm in participants high (H-BPD) and low (L-BPD) in BPD features. Neutral faces were paired with trust-relevant behaviors in four conditions: trustworthy, untrustworthy, ambiguously trustworthy, and mixed trustworthiness. After training, participants rated faces on untrustworthiness as electroencephalographic measures were recorded. H-BPD rated neutral faces as significantly more untrustworthy than L-BPD at both time periods. Negative and ambiguous trustworthiness pairing conditions led to higher ratings of untrustworthiness, whereas trustworthy and mixed descriptors led to lower ratings of untrustworthiness. Learning enhanced the amplitude of an early sensory event-related potential (ERP) component (i.e., P1) for both groups. The slow-wave ERP, an index of sustained attention, revealed greater focus after learning to trustworthy descriptors in H-BPD and to untrustworthy descriptors in L-BPD. H-BPD utilized greater effort to overcome an inherent mistrust bias and L-BPD to overcome unexpected untrustworthy information.

Uncertainty about others' trustworthiness increases during adolescence and guides social information sampling

Adolescence is a key life phase for developing well-adjusted social behaviour. An essential component of well-adjusted social behaviour is the ability to update our beliefs about the trustworthiness of others based on gathered information. Here, we examined how adolescents (n = 157, 10-24 years) sequentially sampled information about the trustworthiness of peers and how they used this information to update their beliefs about others' trustworthiness. Our Bayesian computational modelling approach revealed an adolescence-emergent increase in uncertainty of prior beliefs about others' trustworthiness. As a consequence, early to mid-adolescents (ages 10-16) gradually relied less on their prior beliefs and more on the gathered evidence when deciding to sample more information, and when deciding to trust. We propose that these age-related differences could be adaptive to the rapidly changing social environment of early and mid-adolescents. Together, these findings contribute to the understanding of adolescent social development by revealing adolescent-emergent flexibility in prior beliefs about others that drives adolescents' information sampling and trust decisions.

Impulsivity and Emotional Dysregulation Predict Choice Behavior During a Mixed-Strategy Game in Adolescents With Borderline Personality Disorder

Impulsivity and emotional dysregulation are two core features of borderline personality disorder (BPD), and the neural mechanisms recruited during mixed-strategy interactions overlap with frontolimbic networks that have been implicated in BPD. We investigated strategic choice patterns during the classic two-player game, Matching Pennies, where the most efficient strategy is to choose each option randomly from trial-to-trial to avoid exploitation by one’s opponent. Twenty-seven female adolescents with BPD (mean age: 16 years) and twenty-seven age-matched female controls (mean age: 16 years) participated in an experiment that explored the relationship between strategic choice behavior and impulsivity in both groups and emotional dysregulation in BPD. Relative to controls, BPD participants showed marginally fewer reinforcement learning biases, particularly decreased lose-shift biases, increased variability in reaction times (coefficient of variation; CV), and a greater percentage of anticipatory decisions. A subset of BPD participants with high levels of impulsivity showed higher overall reward rates, and greater modulation of reaction times by outcome, particularly following loss trials, relative to control and BPD participants with lower levels of impulsivity. Additionally, BPD participants with higher levels of emotional dysregulation showed marginally increased reward rate and increased entropy in choice patterns. Together, our preliminary results suggest that impulsivity and emotional dysregulation may contribute to variability in mixed-strategy decision-making in female adolescents with BPD.

Expectation of Selfishness From Others in Borderline Personality Disorder

Social difficulties are apparent in borderline personality disorder (BPD). Behavior in BPD is characterized by mistrust and expectations of malevolence from others. We examined whether there is an asymmetry between their social behavior and their belief about other people’s social motivations. Subjects completed a task where they had to allocate money between themselves and an imagined other they will not meet and interact with. In addition they also had to report their expectations about how the imagined other would solve the task. We hypothesized that even though BPD patients will act in a prosocial way, they will expect selfish behavior from the other. We used the Slider Measure of social value orientation (SVO) and also created a modified version of the measure to examine the discrepancy between the subjects’ own SVO and their expectations from other people. We compared the results of thirty clinically diagnosed BPD patients to a matched sample of healthy participants. Our results show that the BPD group’s selfishness expectations significantly outweigh the expectations of selfishness in the HC group (U = 269, p = 0.007). This result further supports the mistrust and negativity bias observed in various aspects of social interactions in BPD.

Mindreading and metacognition patterns in patients with borderline personality disorder: experimental study

Current psychopathology attempts to understand personality disorders in relation to deficits in higher cognition such as mindreading and metacognition. Deficits in mindreading are usually related to limitations in or a complete lack of the capacity to understand and attribute mental states to others, while impairments in metacognition concern dysfunctional control and monitoring of one's own processes. The present study investigated dysfunctional higher cognition in the population of patients with borderline personality disorder (BPD) by analyzing the accuracy of metacognitive judgments in a mindreading task [reading the mind in the eyes Test (RMET)] and a subsequent metacognitive task based on self-report scales: a confidence rating scale (CR) versus a post-decision wagering scale (PDW). It turned out that people from the BPD group scored lower in the RMET. However, both groups had the same levels of confidence on the PDW scale when giving incorrect answers in the RMET test. As initially hypothesized, individuals with BPD overestimated their confidence in incorrect answers, regardless of the type of metacognitive scales used. The present findings indicate that BPD individuals show dysfunctional patterns between instances of mindreading and metacognition.

The relation between epistemic trust and borderline pathology in an adolescent inpatient sample

BACKGROUND

Recent extensions of mentalization theory have included the hypothesis that a reduced capacity for epistemic trust in the context of attachment relationships may represent a core vulnerability for the development of borderline personality disorder (BPD). The first aim of the current study was to explore empirical relationships between epistemic trust and symptoms of BPD. The second aim was to explore the effect of epistemic trust on treatment response.

METHODS

Data were collected from 322 inpatient adolescents. The Inventory of Parent and Peer Attachment (IPPA) trust in mother and father subscales were used to approximate epistemic trust in the absence of a validated measure. A multimodal approach was used to measure BPD including self-report, parent-report, and interviewer ratings. Regression analyses were performed to explore the relationship between IPPA trust scores and measures of BPD. Mixed-design analyses of variance were conducted to evaluate whether self-reported parent trust at admission influenced progress in treatment.

RESULTS

As hypothesized, results indicated that reduced IPPA trust in parents correlated with BPD symptoms across various measures. Levels of IPPA trust in parents at admission did not moderate a reduction in BPD symptoms over the course of treatment.

CONCLUSIONS

This study provides support for the theoretical association between deficits in epistemic trust and BPD while also highlighting the need for a validated measure of epistemic trust. Although parent trust at admission did not moderate a reduction in BPD symptoms over the course of treatment, this result may suggest that progress in treatment, and perhaps the ability to cultivate trust in the treatment setting and providers, may not be overly determined by levels of parent trust.

A Neuroscience-Oriented Research Approach to Borderline Personality Disorder

Traditionally, the study of personality disorders had been based on psychoanalytic or behavioral models. Over the past two decades, there has been an emerging neuroscience model of borderline personality disorder (BPD) grounded in the concept of BPD as a condition in which dysfunctional neural circuits underlie its pathological dimensions, some of which include emotion dysregulation (broadly encompassing affective instability, negative affectivity, and hyperarousal), abnormal interpersonal functioning, and impulsive aggression. This article, initiated at a joint Columbia University- Cornell University Think Tank on BPD with representation from the Icahn School of Medicine at Mount Sinai, suggests how to advance research in BPD by studying the dimensions that underlie BPD in addition to studying the disorder as a unitary diagnostic entity. We suggest that linking the underlying neurobiological abnormalities to behavioral symptoms of the disorder can inform a research agenda to better understand BPD with its multiple presentations.

Treatment-induced brain plasticity in borderline personality disorder: review of functional MRI studies

Although neural substrates of symptoms expression in borderline personality disorder (BPD) have been studied extensively, neural mechanisms mediating post treatment amelioration of symptoms remain poorly characterized. Herein present review sheds a critical light on all here-to-date functional MRI findings of brain changes in BPD patients following a treatment with psychotherapy or drugs. Preliminary evidence points to downregulation of neuronal activity within the insula and amygdala, together with differential employment of prefrontal areas, mainly orbitofrontal cortex, anterior cingulate cortex and dorsolateral prefrontal cortex, as well as enhanced functional connectivity between limbic and prefrontal regions induced by dialectical behavioral therapy. Identifying neural circuits behind treatment processes may refine strategies to target specific symptoms, thereby resolving some of the controversies over BPD treatment.

Intact implicit statistical learning in borderline personality disorder

Wide-spread neuropsychological deficits have been identified in borderline personality disorder (BPD). Previous research found impairments in decision making, declarative memory, working memory and executive functions; however, no studies have focused on implicit learning in BPD yet. The aim of our study was to investigate implicit statistical learning by comparing learning performance of 19 BPD patients and 19 healthy, age-, education- and gender-matched controls on a probabilistic sequence learning task. Moreover, we also tested whether participants retain the acquired knowledge after a delay period. To this end, participants were retested on a shorter version of the same task 24h after the learning phase. We found intact implicit statistical learning as well as retention of the acquired knowledge in this personality disorder. BPD patients seem to be able to extract and represent regularities implicitly, which is in line with the notion that implicit learning is less susceptible to illness compared to the more explicit processes.

Impaired Maintenance of Interpersonal Synchronization in Musical Improvisations of Patients with Borderline Personality Disorder

Borderline personality disorder (BPD) is a serious and complex mental disorder with a lifetime prevalence of 5.9%, characterized by pervasive difficulties with emotion regulation, impulse control, and instability in interpersonal relationships and self-image. Impairments in interpersonal functioning have always been a prominent characteristic of BPD, indicating a need for research to identify the specific interpersonal processes that are problematic for diagnosed individuals. Previous research has concentrated on self-report questionnaires, unidirectional tests, and experimental paradigms wherein the exchange of social signals between individuals was not the focus. We propose joint musical improvisation as an alternative method to investigate interpersonal processes. Using a novel, carefully planned, ABA' accompaniment paradigm, and taking into account the possible influences of mood, psychotropic medication, general attachment, and musical sophistication, we recorded piano improvisations of 16 BPD patients and 12 matched healthy controls. We hypothesized that the insecure attachment system associated with BPD would be activated in the joint improvisation and manifest in measures of timing behavior. Results indicated that a logistic regression model, built on differences in timing deviations, predicted diagnosis with 82% success. More specifically, over the course of the improvisation B section (freer improvisation), controls' timing deviations decreased (temporal synchrony became more precise) whereas that of the patients with BPD did not, confirming our hypothesis. These findings are in accordance with previous research, where BPD is characterized by difficulties in attachment relationships such as maintaining strong attachment with others, but it is novel to find empirical evidence of such issues in joint musical improvisation. We suggest further longitudinal research within the field of music therapy, to study how recovery of these timing habits are related to attachment experiences and interpersonal functioning in general.

Disadvantageous decision-making in borderline personality disorder: Partial support from a meta-analytic review

To achieve long-term goals, organisms evaluate outcomes and expected consequences of their behaviors. Unfavorable decisions maintain many symptoms of borderline personality disorder (BPD); therefore, a better understanding of the mechanisms underlying decision-making in BPD is needed. In this review, the current literature comparing decision-making in patients with BPD versus healthy controls is analyzed. Twenty-eight empirical studies were identified through a structured literature search. The effect sizes from studies applying comparable experimental tasks were analyzed. It was found that (1) BPD patients discounted delayed rewards more strongly; (2) reversal learning was not significantly altered in BPD; and (3) BPD patients achieved lower net gains in the Iowa Gambling Task (IGT). Current psychotropic medication, sex and differences in age between the patient and control group moderated the IGT outcome. Altered decision-making in a variety of other tasks was supported by a qualitative review. In summary, current evidence supports the altered valuation of outcomes in BPD. A multifaceted influence on decision-making and adaptive learning is reflected in this literature.

Borderline Personality Disorder: Therapeutic Factors

Proponents of the now half-dozen major psychotherapeutic approaches tend to claim the superiority of their different approaches-known widely by their acronyms: CBT for Cognitive Behavioral Therapy, DBT for Dialectic Behavioral Therapy, MBT for Mentalization-Based Therapy, TFP for Transference- Focused Psychotherapy, and so on. The data thus far support the utility of each method, but do not show clear-cut superiority of any one method. A large percentage of BPD patients eventually improve or even recover, but these favorable results appear to derive from a multiplicity of factors. These include the personality traits of both patient and therapist, the unpredictable life events over time, the socioeconomic and cultural background of the patient, and the placebo effect of simply being in treatment. These latter factors constitute the contextual model, which operates alongside the medical model, each playing a role in eventual outcome. The contextual model will be discussed extensively in a separate article.

Inconsistency and social decision making in patients with Borderline Personality Disorder

Inconsistent social behavior is a core psychopathological feature of borderline personality disorder. The goal of the present study was to examine inconsistency in social decision-making using simple economic social experiments. We investigated the decisions of 17 female patients with BPD, 24 patients with major depressive disorder (MDD), and 36 healthy controls in three single shot economic experiments measuring trust, cooperation, and punishment. BPD severity was assessed using the Zanarini Rating Scale for BPD. Investments across identical one-shot trust and punishment games were significantly more inconsistent in BPD patients than in controls. Such inconsistencies were only found in the social risk conditions of the trust and punishment conditions but not in the non-social control conditions. MDD patients did not show such inconsistencies. Furthermore, social support was negatively correlated with inconsistent decision-making in the trust and punishment game, which underscores the clinical relevance of this finding.

EMOTICOM: A Neuropsychological Test Battery to Evaluate Emotion, Motivation, Impulsivity, and Social Cognition

In mental health practice, both pharmacological and non-pharmacological treatments are aimed at improving neuropsychological symptoms, including cognitive and emotional impairments. However, at present there is no established neuropsychological test battery that comprehensively covers multiple affective domains relevant in a range of disorders. Our objective was to generate a standardized test battery, comprised of existing, adapted and novel tasks, to assess four core domains of affective cognition (emotion processing, motivation, impulsivity and social cognition) in order to facilitate and enhance treatment development and evaluation in a broad range of neuropsychiatric disorders. The battery was administered to 200 participants aged 18-50 years (50% female), 42 of whom were retested in order to assess reliability. An exploratory factor analysis identified 11 factors with eigenvalues greater than 1, which accounted for over 70% of the variance. Tasks showed moderate to excellent test-retest reliability and were not strongly correlated with demographic factors such as age or IQ. The EMOTICOM test battery is therefore a promising tool for the assessment of affective cognitive function in a range of contexts.

Oxytocin Conditions Intergroup Relations Through Upregulated In-Group Empathy, Cooperation, Conformity, and Defense

Humans live in, rely on, and contribute to groups. Evolution may have biologically prepared them to quickly identify others as belonging to the in-group (vs. not), to decode emotional states, and to empathize with in-group members; to learn and conform to group norms and cultural practices; to extend and reciprocate trust and cooperation; and to aggressively protect the in-group against outside threat. We review evidence that these components of human group psychology rest on and are modulated by the hypothalamic neuropeptide oxytocin. It appears that oxytocin motivates and enables humans to 1) like and empathize with others in their groups, 2) comply with group norms and cultural practices, and 3) extend and reciprocate trust and cooperation, which may give rise to intergroup discrimination and sometimes defensive aggression against threatening (members of) out-groups. We explore the possibility that deficiencies in (components of) group psychology, seen in autistic spectrum disorder, schizophrenia, and borderline personality and social anxiety disorders, may be reduced by oxytocin administration. Avenues for new research are highlighted, and implications for the role of oxytocin in cooperation and competition within and between groups are discussed.

Borderline personality features and associated difficulty in emotion perception: An examination of accuracy and bias

Research on borderline personality disorder (BPD) has consistently found that those with the disorder often experience volatile interpersonal interactions, and several areas of research have been dedicated to the understanding of the mechanisms behind these interpersonal struggles. One of the most common theories is that the emotional dysregulation that is characteristic of BPD may adversely impact these interpersonal interactions, perhaps through a resulting misperception of emotional states in others. The purpose of the current study was to examine perception of negative affect in those with borderline personality features using a signal detection paradigm, a modified version of the Reading the Mind in the Eyes Task. Results support the hypothesis of atypical perception of negative emotions in BPD, but with disinhibitory aspects of the disorder demonstrating the largest potential influence. This finding was obtained even after controlling for gender differences that were also observed on this task. These results suggest that an examination of trait components of BPD may be necessary for a complete understanding of the emotion perception abilities of those with the disorder.

Altered social decision making in borderline personality disorder: an Ultimatum Game study

The authors examined social decision-making strategies in borderline personality disorder (BPD) using the Ultimatum Game (UG). They sought to extend previous findings by investigating altruistic punishment, a behavior that increases group cooperation in the long term. They tested the effect of the proposer's facial expression on responses. BPD patients (n = 47) and healthy controls (n = 43) played the responder's role in a series of computerized UG interactions, with proposers expressing positive or negative emotions. BPD patients accepted unfair offers at a higher rate compared to controls. The effect of facial expression differed in the two groups, as positive expressions increased the acceptance likelihood in the control group at stakes from 20:80 to 50:50. In the BPD group, this effect was observed only at higher stakes (40:60 and 50:50). These results suggest that BPD patients exhibit altruistic punishment to a lesser extent and are less influenced by their partners' emotional expression in the UG.

Willing to give but not to forgive: borderline personality features and cooperative behavior

Impaired cooperation has been proposed to contribute to social dysfunctioning in borderline personality disorder (BPD). However, prior research has not distinguished active from reactive cooperation (i.e., nonexploitation versus non-retaliation)--two aspects of cooperative behavior associated with different basic personality traits (viz. Honesty-Humility and Agreeableness). The authors hypothesized that, due to low levels of Agreeableness, but normal levels of Honesty-Humility, borderline personality (BP) features are related to impaired reactive cooperation, but unrelated to active cooperation. Participants (N = 559) hypothetically played both the allocator in the dictator game and the recipient in the ultimatum game. High levels of BP features predicted impaired reactive cooperation in the ultimatum game, which was mediated through low Agreeableness. In contrast, BP features did not predict active cooperation in the dictator game-mirroring the nonassociation between BP features and Honesty-Humility. The findings highlight the importance of focusing on aspects of forgiveness in interventions aiming to improve cooperativeness in BPD.

Patient-reported outcomes in borderline personality disorder

Patient-reported outcome (PRO) refers to measures that emphasize the subjective view of patients about their health-related conditions and behaviors. Typically, PROs include self-report questionnaires and clinical interviews. Defining PROs for borderline personality disorder (BPD) is particularly challenging given the disorder's high symptomatic heterogeneity, high comorbidity with other psychiatric conditions, highly fluctuating symptoms, weak correlations between symptoms and functional outcomes, and lack of valid and reliable experimental measures to complement self-report data. Here, we provide an overview of currently used BPD outcome measures and discuss them from clinical, psychometric, experimental, and patient perspectives. In addition, we review the most promising leads to improve BPD PROs, including the DSM-5 Section III, the Recovery Approach, Ecological Momentary Assessments, and novel experimental measures of social functioning that are associated with functional and social outcomes.

Social cognition in borderline personality disorder

Many typical symptoms of borderline personality disorder (BPD) occur within interpersonal contexts, suggesting that BPD is characterized by aberrant social cognition. While research consistently shows that BPD patients have biases in mental state attribution (e.g., evaluate others as malevolent), the research focusing on accuracy in inferring mental states (i.e., cognitive empathy) is less consistent. For complex and ecologically valid tasks in particular, emerging evidence suggests that individuals with BPD have impairments in the attribution of emotions, thoughts, and intentions of others (e.g., Preißler et al., 2010). A history of childhood trauma and co-morbid PTSD seem to be strong additional predictors for cognitive empathy deficits. Together with reduced emotional empathy and aberrant sending of social signals (e.g., expression of mixed and hard-to-read emotions), the deficits in mental state attribution might contribute to behavioral problems in BPD. Given the importance of social cognition on the part of both the sender and the recipient in maintaining interpersonal relationships and therapeutic alliance, these impairments deserve more attention.

Understanding interpersonal function in psychiatric illness through multiplayer economic games

Interpersonal factors play significant roles in the onset, maintenance, and remission of psychiatric conditions. In the current major diagnostic classification systems for psychiatric disorders, some conditions are defined by the presence of impairments in social interaction or maintaining interpersonal relationships; these include autism, social phobia, and the personality disorders. Other psychopathologies confer significant difficulties in the social domain, including major depression, posttraumatic stress disorder, and psychotic disorders. Still other mental health conditions, including substance abuse and eating disorders, seem to be exacerbated or triggered in part by the influence of social peers. For each of these and other psychiatric conditions, the extent and quality of social support is a strong determinant of outcome such that high social support predicts symptom improvement and remission. Despite the central role of interpersonal factors in psychiatric illness, the neurobiology of social impairments remains largely unexplored, in part due to difficulties eliciting and quantifying interpersonal processes in a parametric manner. Recent advances in functional neuroimaging, combined with multiplayer exchange games drawn from behavioral economics, and computational/quantitative approaches more generally, provide a fitting paradigm within which to study interpersonal function and dysfunction in psychiatric conditions. In this review, we outline the importance of interpersonal factors in psychiatric illness and discuss ways in which neuroeconomics provides a tractable framework within which to examine the neurobiology of social dysfunction.

Facial emotional expression in reaction to social exclusion in borderline personality disorder

BACKGROUND

Disturbances in social interaction are a defining feature of patients with borderline personality disorder (BPD). In this study, facial emotional expressions, which are crucial for adaptive interactions in social contexts, were assessed in patients with BPD in response to social exclusion.

METHOD

We examined facial emotional reactions of 35 patients with BPD and 33 healthy controls when playing Cyberball, a virtual ball-tossing game that reliably induces social exclusion. Besides self-reported emotional responses, facial emotional expressions were analyzed by applying the Emotional Facial Action Coding System (EMFACS).

RESULTS

Patients with BPD showed a biased perception of participation. They more readily reported feeling excluded compared to controls even when they were included. In BPD, social exclusion led to an increase in self-reported other-focused negative emotions. Overall, EMFACS analyses revealed that BPD patients reacted with fewer positive expressions and with significantly more mixed emotional expressions (two emotional facial expressions at the same time) compared to the healthy control group when excluded.

CONCLUSIONS

Besides a negative bias for perceived social participation, ambiguous facial emotional expressions may play an important role in the disturbed relatedness in patients with BPD.

Preliminary findings: neural responses to feedback regarding betrayal and cooperation in adolescent anxiety disorders

We compared neural and behavioral responses to feedback received during interpersonal interactions within the Prisoner's Dilemma game between adolescents with anxiety disorders (n = 12) and healthy peers (n = 17). Groups differed significantly in neural activation in the medial prefrontal cortex (mPFC), anterior cingulate cortex (ACC), precuneus, insula, and temporoparietal junction (TPJ). Anxious adolescents were also more likely than controls to cooperate after co-player betrayal. Our findings provide evidence that social behavior and related neural activity differs between anxious and healthy adolescents. These findings constitute a step toward elucidating neural correlates of social impairment in anxious youths.

Superior 'theory of mind' in borderline personality disorder: an analysis of interaction behavior in a virtual trust game

To gain further insight into interpersonal dysfunction in Borderline Personality Disorder (BPD) we investigated the effects of emotional cues and the fairness of a social partner on the ability to infer other peoples' intentions in a virtual social exchange. 30 BPD patients and 30 nonpatients were asked to play a multiround trust game with four virtual trustees. The trustees varied in regard to fairness and presence of emotional facial cues which were both linked to repayment ratio. BPD patients adjusted their investment to the fairness of their partner. In contrast, nonpatients disregarded the trustees' fairness in the presence of emotional facial expressions. Both groups performed equally in an emotion recognition task and assessed the trustees' fairness comparably. When the unfair trustee provided emotional cues, BPD patients assessed their own behavior as more fair, while the lack of cues led patients to assess their own behavior as unfair. BPD patients are superior in the attribution of mental states to interaction partners when emotional cues are present. While the emotional expressions of a partner dominated the exchange behavior in nonpatients, BPD patients used the objective fairness of their social counterparts to guide their own behavior despite the existence of emotional cues.

Neuroeconomic approaches to mental disorders

The pervasiveness of decision-making in every area of human endeavor highlights the importance of understanding choice mechanisms and their detailed relationship to underlying neurobiological function. This review surveys the recent and productive application of game-theoretic probes (economic games) to mental disorders. Such games typically possess concrete concepts of optimal play, thus providing quantitative ways to track when subjects' choices match or deviate from optimal. This feature equips economic games with natural classes of control signals that should guide learning and choice in the agents that play them. These signals and their underlying physical correlates in the brain are now being used to generate objective biomarkers that may prove useful for exposing and understanding the neurogenetic basis of normal and pathological human cognition. Thus, game-theoretic probes represent some of the first steps toward producing computationally principled, objective measures of cognitive function and dysfunction useful for the diagnosis, treatment, and understanding of mental disorders.

Functional neuroimaging of mentalizing during the trust game in social anxiety disorder

Individuals with generalized social anxiety disorder tend to make overly negative and distorted predictions about social events, which enhance perceptions of threat and contribute to excessive anxiety in social situations. Here, we coupled functional magnetic resonance imaging and a multiround economic exchange game ('trust game') to probe mentalizing, the social-cognitive ability to attribute mental states to others. Relative to interactions with a computer, those with human partners ('mentalizing') elicited less activation of medial prefrontal cortex in generalized social anxiety patients compared with matched healthy control participants. Diminished medial prefrontal cortex function may play a role in the social-cognitive pathophysiology of social anxiety.