Mechanisms of disturbed emotion processing and social interaction in borderline personality disorder: state of knowledge and research agenda of the German Clinical Research Unit

Differential methylation of OPRK1 in borderline personality disorder is associated with childhood trauma

According to a growing body of neurobiological evidence, the core symptoms of borderline personality disorder (BPD) may be linked to an opioidergic imbalance between the hedonic and stimulatory activity of mu opioid receptors (MOR) and the reward system inhibiting effects of kappa opioid receptors (KOR). Childhood trauma (CT), which is etiologically relevant to BPD, is also likely to lead to epigenetic and neurobiological adaptations by extensive activation of the stress and endogenous opioid systems. In this study, we investigated the methylation differences in the promoter of the KOR gene (OPRK1) in subjects with BPD (N = 47) and healthy controls (N = 48). Comparing the average methylation rates of regulatorily relevant subregions (specified regions CGI-1, CGI-2, EH1), we found no differences between BPD and HC. Analyzing individual CG nucleotides (N = 175), we found eight differentially methylated CG sites, all of which were less methylated in BPD, with five showing highly interrelated methylation rates. This differentially methylated region (DMR) was found on the falling slope (5') of the promoter methylation gap, whose effect is enhanced by the DMR hypomethylation in BPD. A dimensional assessment of the correlation between disease severity and DMR methylation rate revealed DMR hypomethylation to be negatively associated with BPD symptom severity (measured by BSL-23). Finally, analyzing the influence of CT on DMR methylation, we found DMR hypomethylation to correlate with physical and emotional neglect in childhood (quantified by CTQ). Thus, the newly identified DMR may be a biomarker of the risks caused by CT, which likely epigenetically contribute to the development of BPD.

Evidence of deviant parasympathetic response to social exclusion in women with borderline personality disorder

Stressful social situations like social exclusion are particularly challenging for patients with borderline personality disorder (BPD) and often lead to dysfunctional reactive behaviour of aggression and withdrawal. The autonomous signature of these core symptoms of BPD remains poorly understood. The present study investigated the parasympathetic response to social exclusion in women with BPD (n = 62) and healthy controls (HC; n = 87). In a between-subjects design, participants experienced objective social exclusion or overinclusion in the Cyberball task, a virtual ball-tossing game. Need threat scores served as individual measures of perceived exclusion and the resulting frustration of cognitive-emotional needs. Five-minute measurements of high-frequency heart rate variability (HF-HRV) at three time points (before, during, after Cyberball) indicated parasympathetic tone and regulation. We observed a trend towards lowered baseline HF-HRV in BPD vs. HC in line with previous findings. Interestingly, the parasympathetic response of patients with BPD to objective and perceived social exclusion fundamentally differed from HC: higher exclusion was associated with increased parasympathetic activation in HC, while this autonomic response was reversed and blunted in BPD. Our findings suggest that during social stress, the parasympathetic nervous system fails to display an adaptive regulation in patients with BPD, but not HC. Understanding the autonomous signature of the stress response in BPD allows the formulation of clinically relevant and biologically plausible interventions to counteract parasympathetic dysregulation in this clinical group.

Evidence for a shared genetic contribution to loneliness and borderline personality disorder

Loneliness, influenced by genetic and environmental factors such as childhood maltreatment, is one aspect of interpersonal dysfunction in Borderline Personality Disorder (BPD). Numerous studies link loneliness and BPD and twin studies indicate a genetic contribution to this association. The aim of our study was to investigate whether genetic predisposition for loneliness and BPD risk overlap and whether genetic risk for loneliness contributes to higher loneliness reported by BPD patients, using genome-wide genotype data. We assessed the genetic correlation of genome-wide association studies (GWAS) of loneliness and BPD using linkage disequilibrium score regression and tested whether a polygenic score for loneliness (loneliness-PGS) was associated with case-control status in two independent genotyped samples of BPD patients and healthy controls (HC; Witt2017-sample: 998 BPD, 1545 HC; KFO-sample: 187 BPD, 261 HC). In the KFO-sample, we examined associations of loneliness-PGS with reported loneliness, and whether the loneliness-PGS influenced the association between childhood maltreatment and loneliness. We found a genetic correlation between the GWAS of loneliness and BPD in the Witt2017-sample (rg = 0.23, p = 0.015), a positive association of loneliness-PGS with BPD case-control status (Witt2017-sample: NkR² = 2.3%, p = 2.7*10-12; KFO-sample: NkR² = 6.6%, p = 4.4*10-6), and a positive association between loneliness-PGS and loneliness across patient and control groups in the KFO-sample (β = 0.186, p = 0.002). The loneliness-PGS did not moderate the association between childhood maltreatment and loneliness in BPD. Our study is the first to use genome-wide genotype data to show that the genetic factors underlying variation in loneliness in the general population and the risk for BPD overlap. The loneliness-PGS was associated with reported loneliness. Further research is needed to investigate which genetic mechanisms and pathways are involved in this association and whether a genetic predisposition for loneliness contributes to BPD risk.

Interpersonal Trust and Borderline Personality Disorder: Insights From Clinical Practice and Research: Introduction

Individuals suffering from borderline personality disorder (BPD) show a pervasive sense that others cannot be trusted, are vulnerable to negative therapeutic reactions, and can oscillate between idealized and persecutory interactions with others. These trust processing impairments impact both the immediate and wider social milieu of individuals with BPD, including therapist-patient interactions. Recently, research started unraveling the social-cognitive mechanisms of these impairments in BPD. In this Special Issue, we attempt to close the gap between research findings and clinical theories on trust processing impairment in BPD. The first section includes five original studies on trust processing in BPD. The second section includes five articulations of trust processing impairment as a treatment target in evidence-based treatments for BPD and as an indispensable "common factor" in the treatment of BPD. These cutting-edge research and clinical contributions advance a potential integrative, clinical science framework for conceptualizing and intervening effectively with those who struggle with BPD.

One Year of Outpatient Dialectical Behavioral Therapy and Its Impact on Neuronal Correlates of Attachment Representation in Patients with Borderline Personality Disorder Using a Personalized fMRI Task

(1) Background: BPD is characterized by affect dysregulation, interpersonal problems, and disturbances in attachment, but neuroimaging studies investigating attachment representations in BPD are rare. No study has examined longitudinal neural changes associated with interventions targeting these impairments. (2) Methods: We aimed to address this gap by performing a longitudinal neuroimaging study on n = 26 patients with BPD treated with Dialectic Behavioral Therapy (DBT) and n = 26 matched healthy controls (HCs; post intervention point: n = 18 BPD and n = 23 HCs). For functional imaging, we applied an attachment paradigm presenting attachment related scenes represented in drawings paired with related neutral or personalized sentences from one's own attachment narratives. In a prior cross-sectional investigation, we identified increased fMRI-activation in the human attachment network, in areas related to fear response and the conflict monitoring network in BPD patients. These were especially evident for scenes from the context of loneliness (monadic pictures paired with individual narrative sentences). Here, we tested whether these correlates of attachment representation show a near-to-normal development over one year of DBT intervention. In addition, we were interested in possible associations between fMRI-activation in these regions-of-interest (ROI) and clinical scores. (3) Results: Patients improved clinically, showing decreased symptoms of borderline personality organization (BPI) and increased self-directedness (Temperament and Character Inventory, TCI) over treatment. fMRI-activation was increased in the anterior medial cingulate cortex (aMCC) and left amygdala in BPD patients at baseline which was absent after intervention. When investigating associations between scores (BPI, TCI) and functional activation, we found significant effects in the bilateral amygdala. In contrast, aMCC activation at baseline was negatively associated with treatment outcome, indicating less effective treatment effects for those with higher aMCC activation at baseline. (4) Conclusions: Monadic attachment scenes with personalized sentences presented in an fMRI setup are capable of identifying increased activation magnitude in BPD. After successful DBT treatment, these increased activations tend to normalize which could be interpreted as signs of a better capability to regulate intensive emotions in the context of "social pain" towards a more organized/secure attachment representation. Amygdala activation, however, indicates high correlations with pre-treatment scores; activation in the aMCC is predictive for treatment gain. Functional activation of the amygdala and the aMCC as a response to attachment scenes representing loneness at baseline might be relevant influencing factors for DBT-intervention outcomes.

A systematic review and meta-analysis of digital interventions targeted at individuals with borderline personality disorder (BPD), emotionally unstable personality disorder (EUPD), and related symptoms

OBJECTIVES

The present review investigates the impact of digital interventions for individuals with features of borderline personality disorder (BPD)/emotional unstable personality disorder (EUPD) as digital interventions show promise as therapeutic tools in underserved groups. BPD/EUPD features are identified as clinically relevant, yet previous reviews on the use of digital interventions fail to include subthreshold symptomatology.

METHODS

Five online databases were searched for terminology in three categories: BPD/EUPD and related symptoms, mental-health interventions, and digital technology. Additionally, four relevant journals and two trial registers were searched for additional papers meeting the inclusion criteria.

RESULTS

Twelve articles met all inclusion criteria. Meta-analyses revealed statistically significant differences in symptom measures between intervention and control groups at postintervention and decreases in BPD/EUPD symptomatology and well-being from pre- to postintervention. Service users' engagement, satisfaction, and acceptability of interventions were high. Results support the previous literature on the value of using digital interventions in populations with BPD/EUPD.

CONCLUSION

Overall, it was identified that digital interventions show promise for successful implementation with this population.

Adverse childhood experiences mediate the negative association between borderline personality disorder symptoms and plasma oxytocin

Background Interpersonal dysfunction is a core symptom of borderline personality disorder (BPD) and may be closely linked to adverse childhood experiences. According to a recent model on the pathology of BPD, the neuropeptide oxytocin might play an important role in the development and maintenance of the disorder. However, so far, only few studies with small adult samples have reported reduced baseline oxytocin levels in BPD that may be linked to adverse childhood experiences. Methods We examined baseline plasma oxytocin levels in 131 female patients with BPD and 124 non-BPD female controls across a large age span (12-50 years). Additionally, 113 female patients with less than five DSM-IV BPD features were included to examine the association between plasma oxytocin levels and the number of fulfilled BPD criteria. We also explored associations between plasma oxytocin and adverse childhood experiences as well as depressive symptoms in BPD. Results Patients with BPD had reduced plasma oxytocin levels compared to non-BPD controls and this was independent of age. Plasma oxytocin was negatively associated with the number of fulfilled BPD criteria. The exploratory regression model revealed no association between plasma oxytocin and depressive symptoms but an association between plasma oxytocin and adverse childhood experiences, which in fact mediated the relationship between BPD criteria und plasma oxytocin. Conclusion In a large sample of individuals with BPD across a large age span, our results replicate and extend previous reports of reduced plasma oxytocin levels that might be related to adverse childhood experiences thus providing further evidence for a prominent role of oxytocin in BPD.

Shame, self-disgust, and envy: An experimental study on negative emotional response in borderline personality disorder during the confrontation with the own face

Background

A markedly negative self-image and pervasive shame proneness have consistently been associated with borderline personality disorder (BPD). The present experimental study investigated the intensity of negative emotional responses with a focus on shame in BPD compared to healthy control persons (HCs) during an experimental paradigm promoting self-awareness, self-reflection, and self-evaluation. Furthermore, the relationship between levels of state shame during the experiment and shame proneness in BPD compared to HCs was examined.

Methods

A sample of 62 individuals with BPD and 47 HCs participated in the study. During the experimental paradigm, participants were presented with photos of (i) the own face, (ii) the face of a well-known person, and (iii) of an unknown person. They were asked to describe positive facets of these faces. Participants rated the intensity of negative emotions induced by the experimental task as well the pleasantness of the presented faces. Shame-proneness was assessed using the Test of the Self-Conscious Affect (TOSCA-3).

Results

Individuals with BPD experienced significantly higher levels of negative emotions than HCs both before and during the experimental task. While HC participants responded to their own face particularly with an increase in shame compared to the other-referential condition, the BPD patients responded above all with a strong increase of disgust. Furthermore, the confrontation with an unknown or well-known face resulted in a strong increase of envy in BPD compared to HC. Individuals with BPD reported higher levels of shame-proneness than HCs. Higher levels of shame-proneness were related to higher levels of state shame during the experiment across all participants.

Conclusion

Our study is the first experimental study on negative emotional responses and its relationship to shame proneness in BPD compared to HC using the own face as a cue promoting self-awareness, self-reflection, and self-evaluation. Our data confirm a prominent role of shame when describing positive features of the own face, but they emphasize also disgust and envy as distinct emotional experience characterizing individuals with BPD when being confronted with the self.

Pathophysiological aspects of complex PTSD - a neurobiological account in comparison to classic posttraumatic stress disorder and borderline personality disorder

Despite a great diagnostic overlap, complex posttraumatic stress disorder (CPTSD) has been recognised by the ICD-11 as a new, discrete entity and recent empirical evidence points towards a distinction from simple posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD). The development and maintenance of these disorders is sustained by neurobiological alterations and studies using functional magnetic resonance imaging (fMRI) may further contribute to a clear differentiation of CPTSD, PTSD and BPD. However, there are no existing fMRI studies directly comparing CPTSD, PTSD and BPD. In addition to a summarization of diagnostic differences and similarities, the current review aims to provide a qualitative comparison of neuroimaging findings on affective, attentional and memory processing in CPTSD, PTSD and BPD. Our narrative review alludes to an imbalance in limbic-frontal brain networks, which may be partially trans-diagnostically linked to the degree of trauma symptoms and their expression. Thus, CPTSD, PTSD and BPD may underlie a continuum where similar brain regions are involved but the direction of activation may constitute its distinct symptom expression. The neuronal alterations across these disorders may conceivably be better understood along a symptom-based continuum underlying CPTSD, PTSD and BPD. Further research is needed to amend for the heterogeneity in experimental paradigms and sample criteria.

Disgust as a transdiagnostic index of mental illness: A narrative review of clinical populations

Disgust is a basic emotion of rejection, providing an ancestral defensive mechanism against illness. Based on research that documents altered experiences of disgust across several psychopathological conditions, we conducted a narrative review to address the hypothesis that altered disgust may serve as a transdiagnostic index of mental illness. Our synthesis of the literature from past decades suggests that, compared to healthy populations, patients with mental disorders exhibit abnormal processing of disgust in at least one of the analyzed dimensions. We also outline evidence of alterations in brain areas relevant to disgust processing, such as the insula and the interconnected limbic network. Overall, we provide preliminary support for the hypothesis that altered disgust processing may serve as a transdiagnostic index of mental illness.

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.

Aggression in borderline personality disorder: A systematic review of neuroimaging studies

Aggressive behaviors are prevalent among patients with Borderline Personality Disorder (BPD). Neuroimaging studies have linked aggression in BPD patients to neurochemical, structural, functional, and metabolic alterations in various brain regions, especially in frontal-limbic areas. This systematic review summarizes current neuroimaging results on aggression among BPD patients and provides an overview of relevant brain mechanisms. A systematic search of PubMed and Web of Science databases, in addition to manual check of references, identified thirty-two eligible articles, including two magnetic resonance spectrum (MRS), thirteen structural magnetic resonance imaging (sMRI), six functional magnetic resonance imaging (fMRI), and eleven positron emission tomography (PET) studies. The reviewed studies have highlighted the abnormalities in prefrontal cortices and limbic structures including amygdala and hippocampus. Less studies have zoomed in the roles of parietal and temporal regions or taken a network perspective. Connectivity studies have shed light on the importance of the frontal-limbic interactions in regulating aggression. Conflicted findings might be attributed to disparity in controlling gender, anatomical subdivisions, and comorbidities, which shall be considered in future studies.

Neural Correlates of Attachment Representation in Patients With Borderline Personality Disorder Using a Personalized Functional Magnet Resonance Imaging Task

Background

Fear of abandonment and aloneness play a key role in the clinical understanding interpersonal and attachment-specific problems in patients with borderline personality disorder (BPD) and has been investigated in previous functional Magnet Resonance Imaging (fMRI) studies. The aim of the present study was to examine how different aspects of attachment representations are processed in BPD, by using for the first time an fMRI attachment paradigm including personalized core sentences from the participants’ own attachment stories. We hypothesized that BPD patients would show increased functional involvement of limbic brain regions associated with fear and pain (e.g., the amygdala and the anterior cingulate cortex) when presented personalized attachment relevant stimuli representing loneliness compared to healthy controls (HC).

Methods

We examined the attachment classifications of 26 female BPD patients and 26 female HC using the Adult Attachment Projective Picture System (AAP). We used an fMRI-adapted attachment paradigm to investigate the neural correlates of attachment. All participants were presented three personalized (vs. neutral) sentences extracted from their AAP attachment narrative, combined with standardized AAP pictures representing being alone (monadic) or in interactive (dyadic) attachment situations.

Results

As expected, the classification of unresolved attachment was significantly greater in BPD compared to HC. BPD patients showed increased fMRI-activation in brain areas associated with fear, pain, and hyperarousal than HC when presented with personalized attachment-relevant alone stimuli. In particular, pictures with monadic attachment situations induced greater anterior medial cingulate cortex, anterior insula, amygdala, thalamus and superior temporal gyrus activation in the patient group.

Conclusion

The results point to increased fMRI-activation in areas processing emotional distress and painful experiences in BPD patients. In particular, the emotional cascade reflecting attachment distress was evoked by combining monadic pictures, representing abandonment and aloneness, with the patients’ personalized narrative material. Our results confirmed and replicated previous results that illustrate once again the high relevance of aloneness and feelings of abandonment for BPD in the context of attachment trauma. Moreover, our results support the hypothesis of hypermentalization in response to attachment distress as a core feature of social-cognitive impairment in BPD associated with common treatment implications across different therapeutic orientations.

Pleasant touch perception in borderline personality disorder and its relationship with disturbed body representation

BACKGROUND

Borderline personality disorder (BPD) is characterized by altered perception of affective stimuli, including abnormal evaluation of nociceptive input. However, whether or not perceptual alterations are present for its positive counterpart, i.e. pleasant touch (PT), has not yet been examined.

METHODS

In the present study, we applied standardized PT stimuli to the hands of 25 patients with BPD and 25 healthy controls (HC) and compared their perception. We used the affect-modulated acoustic startle response as a physiological correlate of affective processing. We further explored the effect of PT stimulation on dissociative experiences in BPD.

RESULTS

Compared to HC, BPD perceived PT as less pleasant and less intense. The effect on perceived valence of touch was large even after controlling for the effect of reduced perceived intensity of touch (ƞ² = .29). We further found qualitative alterations in touch perception in BPD, who rated the touch as significantly rougher and firmer compared to HC. There was a positive correlation between perceived valence of touch and changes in dissociative experiences in terms of body ownership of the stimulated body part from pre to post stimulation, suggesting that a more negative evaluation of touch is associated with an increase in body-related dissociative experiences, while a positive perception of touch might be related to a reduction of these dissociative experiences.

CONCLUSIONS

Our results confirm BPD-associated disturbances in the processing of affective somatosensory stimuli and indicate that not only pain perception but also pleasant touch perception is diminished in BPD. We discuss the role of altered touch perception for BPD psychopathology and its potential role for new treatment approaches.

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.

Cognitive and Affective Theory of Mind in Female Patients With Borderline Personality Disorder

Empirical studies have identified deficits in cognitive and affective theory of mind (ToM) in patients with borderline personality disorder (BPD), but results remain heterogeneous and not much is known about the role of childhood trauma. The current study assessed cognitive and affective ToM in 80 patients with BPD and 41 healthy controls in a false-belief cartoon task. Childhood trauma was measured with the Childhood Trauma Questionnaire (CTQ). Patients with BPD responded slower in all experimental conditions in false-belief situations, but not when false beliefs were resolved; made more errors in the cognitive ToM condition; and reported worse affective states more often in and after false-belief situations. No significant correlations between ToM and childhood trauma could be found. The current study revealed deficits in cognitive and affective ToM in patients with BPD that may be related to a more negative affective state raised by the false-belief stories.

Associations between age and cortisol awakening response in patients with borderline personality disorder

Patients with borderline personality disorder (BPD) often display increased stress vulnerability, which may be linked to altered hypothalamus–pituitary–adrenal (HPA) axis functioning. Corresponding deviations of the cortisol awakening response (CAR) are presumed to mirror maladaptive neuroendocrine processes, which may explain why CARs are increased compared to healthy controls (HC). Prior research speculated that these alterations may be caused by early life stress and/or chronic stress related to the ongoing burden of the disorder. Yet, it remains to be investigated how BPD influences CAR in the course of development. Therefore, the current study examined CAR in female adolescents and adults with BPD compared to HC with a particular focus on associations with age. These potential associations were especially focused, as it was hypothesized that the CAR would be even more elevated (i.e., higher) in older individuals with BPD. CAR was assessed in 54 female individuals with BPD (aged 15–40 years) and 54 sex-, age-, and intelligence-matched HC (aged 15–48 years). Group differences were investigated and analyses of covariance using age as continuous predictor were performed to analyze potential developmental associations with CAR alongside BPD-specific effects. Pearson’s correlations were calculated to examine associations between CAR and age. Analyses were repeated with potential confounders as control factors. Results not only demonstrated increased CARs in female individuals with BPD compared to HC but demonstrated elevated CARs with increasing age in BPD individuals exclusively. Effects remained stable after controlling for potential confounders. Thereby, findings suggest that endocrine alterations in BPD may reinforce with increasing age and BPD chronicity.

Body connection mediates the relationship between traumatic childhood experiences and impaired emotion regulation in borderline personality disorder

BACKGROUND

Previous studies revealed an association between traumatic childhood experiences and emotional dysregulation in patients with borderline personality disorder (BPD). However, possible mediating pathways are still not fully understood. The aim of the present study was to investigate the potential mediating role of body connection, describing the awareness of the relationship of bodily and mental states, for the association between a history of traumatic childhood experiences and BPD core symptomatology.

METHODS

One-hundred-twelve adult female individuals with BPD and 96 healthy female controls (HC) were included. Impaired emotion regulation, traumatic childhood experiences, and BPD symptomatology were assessed with self-report questionnaires. The Scale of Body Connection was used to assess two dimensions of body connection, that is body awareness, describing attendance to bodily information in daily life and noticing bodily responses to emotions and/or environment and body dissociation, describing a sense of separation from one's own body, due to avoidance or emotional disconnection. Mann-Whitney U tests were employed to test for group differences (BPD vs. HC) on the two SBC subscales and associations with clinical symptoms were analyzed with Spearman correlations. We performed mediation analyses in the BPD group to test the assumption that body connection could act as a mediator between a history of traumatic childhood experiences and emotion dysregulation.

RESULTS

Individuals with BPD reported significantly lower levels of body awareness and significantly higher levels of body dissociation compared to HC. Body dissociation, traumatic childhood experiences, and emotion dysregulation were significantly positively associated. Further analyses revealed that body dissociation, but not body awareness, significantly and fully mediated the positive relationship between traumatic childhood experiences and impaired emotion regulation in the BPD sample. This mediation survived when trait dissociation, i.e., general dissociative experiences not necessarily related to the body, was statistically controlled for.

CONCLUSION

Certain dimensions of body connection seem to be disturbed in BPD patients, with body dissociation being an important feature linking a history of traumatic childhood experiences to current deficits in emotion regulation.

The distinctive neural circuitry of complex posttraumatic stress disorder during threat processing

BACKGROUND

There is controversy over the extent to which the new International Classification of Diseases (ICD-11) diagnosis of complex posttraumatic stress disorder (CPTSD) is distinct from posttraumatic stress disorder (PTSD). This study aimed to conduct the first investigation of distinctive neural processes during threat processing in CPTSD relative to PTSD.

METHOD

This cross-sectional functional magnetic resonance study included 99 participants who met criteria for PTSD (PTSD = 32, CPTSD = 28) and 39 trauma-exposed controls. PTSD was assessed with the Clinician-Administered PTSD Scale (CAPS). CPTSD was assessed with an adapted version of the International Trauma Questionnaire. Neural responses were measured across the brain while threat or neutral faces were presented at both supraliminal and subliminal levels.

RESULTS

During supraliminal presentations of threat stimuli, there was greater bilateral insula and right amygdala activation in CPTSD participants relative to PTSD. Reduced supraliminal right dorsolateral prefrontal cortex activation and increased subliminal amygdala and insula activation were observed as common dysfunction for both CPTSD and PTSD groups relative to trauma controls. There were no significant differences in terms of subliminal presentations and no differences in functional connectivity. Dissociative responses were positively associated with right insula activation (r = 0.347, p < 0.01).

CONCLUSIONS

These results provide the first evidence of distinct neural profiles of CPTSD and PTSD during threat processing. The observation of increased insula and right amygdala activation in CPTSD accords with the proposal that CPTSD is distinguished from PTSD by disturbances in emotion regulation and self-concept.

Single-Dose Effects of Citalopram on Neural Responses to Affective Stimuli in Borderline Personality Disorder: A Randomized Clinical Trial

BACKGROUND

Psychiatric medication that has a soothing effect on limbic responses to affective stimuli could improve affective instability symptoms as observed in borderline personality disorder (BPD). The objective of this study was to investigate whether citalopram versus placebo reduces the response of the affective neural circuitry during an emotional challenge.

METHODS

A total of 30 female individuals with a BPD diagnosis participated in a placebo-controlled, double-blind crossover trial design. Three hours after oral drug intake, individuals with BPD viewed affective pictures while undergoing functional magnetic resonance imaging. Blood oxygen level-dependent responses to images of negative affective scenes and faces showing negative emotional expressions were assessed in regions of interest (amygdala, anterior cingulate cortex, anterior insula, dorsolateral prefrontal cortex). Blood perfusion at rest was assessed with arterial spin labeling.

RESULTS

The neural response to pictures showing negative affective scenes was not significantly affected by citalopram (n = 23). Citalopram significantly reduced the amygdala response to pictures of faces with negative affective expressions (n = 25, treatment difference left hemisphere: -0.06 ± 0.16, p < .05; right hemisphere: -0.06 ± 0.17, p < .05). We observed no significant effects of citalopram on the other regions. The drug did not significantly alter blood perfusion at rest.

CONCLUSIONS

Citalopram can alter the amygdala response to affective stimuli in BPD, which is characterized by overly responsive affective neural circuitry.

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.

Don't Make Me Angry: Frustration-Induced Anger and Its Link to Aggression in Women With Borderline Personality Disorder

Aggression is a prominent interpersonal dysfunction of individuals with borderline personality disorder (BPD). In BPD aggression is predominantly reactive in nature, often triggered by frustration, provocation, or social threat and is associated with intense anger and an inability to regulate this strong, negative emotion. Building on previous research, we were interested in investigating negative emotionality in general and anger in particular in women with BPD before and after frustration induction. To achieve this, 60 medication-free women with BPD and 32 healthy women rated the intensity of negative emotions (angry, frustrated, upset, embarrassed, nervous) before and after performing a Titrated Mirror Tracing Task, which reliably induces frustration and distress. As expected, women with BPD reported significantly greater intensity of negative emotions before and after frustration than healthy women. Specifically, they showed a significantly stronger frustration-induced increase in anger, while other negative emotions remained unaffected by frustration induction. This anger increase was significantly related to aggressive behavior reported in the 2 weeks prior to the experiment, as well as to the level of frustration experienced in the experiment itself, but not with emotion dysregulation. The current data confirm the important role of frustration-induced anger independent of emotion dysregulation in BPD, in particular with regard to aggression, a prominent interpersonal dysfunction of this disorder. These findings underline the importance of interventions with particular focus on anger.

Heartbeat evoked potentials in patients with post-traumatic stress disorder: an unaltered neurobiological regulation system?

BACKGROUND

Early life maltreatment is a risk factor for psychiatric disorders, including post-traumatic stress disorder (PTSD). Post-traumatic stress disorder is a severe and heterogeneous disorder with fluctuating states of emotional over- and undermodulation, including hypervigilance, dissociation, and emotion regulation deficits. The perception and regulation of emotions have been linked to interoception, the cortical representation and sensing of inner bodily processes. Although first therapeutic approaches targeting bodily sensations have been found effective in patients with PTSD, and deficits in interoceptive signal representation have been reported in other trauma-related disorders, such as borderline personality disorder (BPD), the role of interoception remains largely unexplored for PTSD.

OBJECTIVE

The objective was to investigate the cortical representation of cardiac interoceptive signals in patients with PTSD and its associations with early life maltreatment, trait dissociation, and emotion dysregulation.

METHODS

Twenty-four medication-free patients with PTSD and 31 healthy controls (HC) completed a 5-min resting electrocardiogram (ECG) with parallel electroencephalogram (EEG). Heartbeat evoked potential (HEP) amplitudes as a measure for cortical representation of cardiac interoceptive signals were compared between groups and correlated with self-report questionnaires.

RESULTS

We did not find significantly different mean HEP amplitudes in patients with PTSD compared to HC, although HEPs of patients with PTSD were descriptively higher. No significant associations between mean HEP amplitudes and early life maltreatment, trait dissociation or emotion dysregulation were obtained within the groups.

CONCLUSION

The current finding does not indicate deficits in interoceptive signal representation at rest in individuals with PTSD. Whether patients with PTSD show altered HEP modulations during emotion regulation tasks and might benefit from therapeutic approaches aiming at changing the perception of bodily signals, needs to be investigated in future studies.

Impact of a Mechanism-Based Anti-Aggression Psychotherapy on Behavioral Mechanisms of Aggression in Patients With Borderline Personality Disorder

Introduction: Aggressive behavior is highly prevalent in patients with borderline personality disorder (BPD) and represents a major burden for patients and their environment. Previous studies have hypothesized threat hypersensitivity, among other mechanisms, as a biobehavioral mechanism underlying aggressive behavior in patients with BPD. The effects of a 6-week mechanism-based anti-aggression psychotherapy (MAAP) for the group setting were tested in comparison to the effects of a non-specific supportive psychotherapy (NSSP) on this hypothesized mechanism and their relation to the effects on aggressive behavior. Methods: To assess mechanisms of reactive aggression, 38 patients with BPD (20 in MAAP and 18 in NSSP) and 24 healthy controls participated in an emotion classification task before and after therapy or at a similar interval of 7 weeks for controls, respectively. In addition, current reactive aggressive behavior was assessed by the externally directed overt aggression score of the Overt Aggression Scale Modified (OAS-M) at both time points. Mixed linear models were used to test for group differences and differential treatment effects. Results: Consistent with previous findings, patients showed longer response latencies and misclassified faces as angry more often than healthy controls. Comparing pre- and post-treatment measurements, the MAAP group showed an increase in response latency in classifying angry faces, whereas the NSSP group showed a decrease in latency. Furthermore, the difference between pre- and post-treatment response latencies in classifying emotional faces correlated with the reductions in reactive aggression in the MAAP group, but not in the NSSP group or healthy controls. Conclusion: The results suggest an impact of MAAP on threat sensitivity as well as cognitive control, which has also been previously hypothesized as a biobehavioral mechanism underlying reactive aggression in patients with BPD. In addition, our findings shed light on the importance of these two biobehavioral mechanisms underlying reactive aggression as mechanisms of change addressed by MAAP. Further studies are needed to determine whether the behavioral change is stable over time and to what extent this change is related to a stable reduction in reactive aggression in a larger group of patients with BPD.

Social interaction patterns, therapist responsiveness, and outcome in treatments for borderline personality disorder

OBJECTIVES

Inflexible social interaction patterns are defining features of borderline personality disorder (BPD). Specific beliefs about the self and others may be activated across interaction situations, often leading to instable relationships. It may be pivotal to address these difficulties in early treatment phases, through appropriate therapist responsiveness, which means an adaptation of therapist's activity to their client's behaviours using emerging information in the process (Stiles, 2009, Clinical Psychology: Science and Practice, 16, 86).

DESIGN

In this process-outcome study, responsiveness is operationalized by the motive-oriented therapeutic relationship (Caspar, 2007, Handbook of psychotherapeutic case formulations, 2nd ed., 251-289, Guilford), based on the Plan analysis case formulation. The present study assesses the interplay between social interaction problems and therapist responsiveness, explaining symptoms at discharge and the therapeutic alliance.

METHOD

In total, N = 50 clients with BPD entered the study, and standard and responsive treatments were compared. Social interaction patterns were assessed by the newly developed Borderline Interaction Patterns Scale (BIPS), applied to recorded material of three sessions per therapy. Outcome was measured by general symptoms (OQ-45), borderline symptoms (BSL-23), interpersonal problems (IIP), and the therapeutic alliance (WAI).

RESULTS

Results suggest that in standard treatment, social interaction patterns are neither related to outcome nor the therapeutic alliance. In responsive treatment, more activation of social interaction patterns predicted better outcome on IIP and lower therapist ratings of the alliance.

CONCLUSIONS

The conclusions seem promising for specific effectiveness of responsive treatments in particular in the interpersonal problem area of BPD. Identifying social interaction patterns early in treatment may be a crucial pathway to change for BPD.

PRACTITIONER POINTS

Responsive therapy activating social interaction patterns may be crucial for better outcome. Future research should focus on mechanisms of change in early treatment phases for BPD. New scale for assessing social interaction patterns specific to borderline personality disorder.

Subjektive Nebenwirkungsklagen von Borderline-Patienten – zwei Jahre nach einer tagesklinischen Behandlung

<b><i>Einleitung:</i></b> Die Erfassung von negativen Effekten (nE) von Psychotherapie (PT) ist wichtig, um Schwachstellen von PT zu identifizieren und die Behandlungsqualität zu verbessern. Studienziel ist, zu untersuchen, welche nE Patienten nach einer tagesklinischen Behandlung für Borderline-Persönlichkeitsstörungen (BPS) mit einem Dialektisch-Behavioralen Therapieschwerpunkt (DBT) beschreiben, welche Einflussfaktoren vorliegen und wie die Klagen inhaltlich zu verstehen sind. <b><i>Material und Methoden:</i></b> Katamnestisch wurden BPS-Patienten 22,6 Monate nach Therapieende befragt, an welche nE sie sich mit Bezug zu einer zwölfwöchigen ta­gesklinischen Behandlung erinnern. Messinstrumente wa­ren BDI, BSL-95 und INEP. <b><i>Ergebnisse:</i></b> 35 Frauen und 6 Männer antworteten (50% von 82). Im Mittel wurden 11,2 nE benannt, die subjektiv auf die DBT-Behandlung zurückgeführt wurden. 97,6% berichten von Verschlechterung ihres Befindens, 87,8% erinnern sich an Probleme in der therapeutischen Beziehung, 43,9% klagten über Verschlechterungen in der Beziehung, 70,7% über finanzielle Probleme in Folge der tagesklinischen Behandlung und 29,3% über Stigmatisierungserleben. Die Zahl der nE korrelierte mit höherem Alter zum Therapiestart (<i>p</i> &#x3c; 0,01) sowie höherer Symptomlast anhand der BSL-95 (<i>p</i> &#x3c; 0,01) bzw. BDI (<i>p</i> &#x3c; 0,01) zum Befragungszeitpunkt. <b><i>Diskussion:</i></b> Es konnte gezeigt werden, dass Patienten bei Vorlage des INEP über eine erheb­liche Rate an Negativerfahrungen im Rahmen der tages­klinischen Behandlung klagen. Der lange Rückerinne­rungszeitraum von 3 bis 51 Monaten und die Korrelation mit der aktuellen Symptomatik stellen die Validität der Antwort in Frage. Ergebnisse von Selbstratinginstrumenten zur Nebenwirkungserfassung bedürfen einer sehr sorgfältigen Interpretation.

Diffusion tensor imaging in borderline personality disorder showing prefrontal white matter alterations

Borderline personality disorder (BPD) has repeatedly been linked to alterations in fronto-limbic dysfunction. In this study, we tested the hypothesis of disturbed structural connectivity in underlying fibre tracts and their relation to symptom profiles. We analysed diffusion tensor imaging (DTI) data from 18 female BPD patients and 38 female healthy controls. Group comparisons showed significant (p < .05, FDR adjusted) increase of radial diffusivity (RD) in the right frontal lobe, including the uncinate fasciculus, anterior thalamic radiation, and inferior fronto-occipital fasciculus, as well as overall apparent diffusion coefficient (ADC) increases in the anterior and posterior internal capsule. Symptom correlations, based on the BSL-95 questionnaires, within the BPD sample showed significant negative correlations of dysphoria with ADC the left and right anterior thalamic radiation, and positive correlations of fractional anisotropy with self-perception scores in the right superior corona radiata. While our findings add to the fronto-limbic dysfunction model of BPD, they provide additional evidence of links to its affective core pathology, particularly frontotemporal and fronto-thalamic systems.

Evaluation of the own body in women with current and remitted borderline personality disorder: evidence for long-lasting effects of childhood sexual abuse

BACKGROUND

Evaluation of one's own body highly depends on psychopathology. In contrast to healthy women, body evaluation is negative in women from several diagnostic groups. Particularly negative ratings have been reported in disorders related to childhood sexual abuse (CSA) including borderline personality disorder (BPD). However, it is unknown whether this negative evaluation persists beyond symptomatic remission, whether it depends on the topography of body areas (sexually connoted versus neutral areas), and whether it depends on CSA.

OBJECTIVE

First, we aimed at a quantitative comparison of body evaluation across three diagnostic groups: current BPD (cBPD), remitted BPD (rBPD), and healthy controls (HC). Second, we aimed at clarifying the potentially moderating role of a history of CSA and of the sexual connotation of body areas.

METHODS

The study included 68 women from the diagnostic groups of interest (cBPD, rBPD, and HC). These diagnoses were established with the International Personality Disorder Examination. The participants used the Survey of Body Areas to quantify the evaluation of the own body and the Childhood Trauma Questionnaire for assessing CSA.

RESULTS

While the evaluation of the own body was generally negative in women from the cBPD group it was positive in those who had remitted from BPD. However, their positive scores were strictly confined to neutral body areas, whereas the evaluation of sexually connoted body areas was negative, resembling the respective evaluation in cBPD patients and contrasting the positive evaluation of sexually connoted areas in healthy women. The negative evaluation of sexually connoted areas in remitted women was significantly related to a history of CSA.

CONCLUSIONS

Women with BPD may require a specifically designed intervention to achieve a positive evaluation of their entire body. The evaluation of sexually connoted body areas seems to remain an issue even after remission from the disorder has been achieved.

Psychophysiological Effects of Downregulating Negative Emotions: Insights From a Meta-Analysis of Healthy Adults

Assessing psychophysiological responses of emotion regulation is a cost-efficient way to quantify emotion regulation and to complement subjective report that may be biased. Previous studies have revealed inconsistent results complicating a sound interpretation of these findings. In the present study, we summarized the existing literature through a systematic search of articles. Meta-analyses were used to evaluate effect sizes of instructed downregulation strategies on common autonomic (electrodermal, respiratory, cardiovascular, and pupillometric) and electromyographic (corrugator activity, emotion-modulated startle) measures. Moderator analyses were conducted, with moderators including study design, emotion induction, control instruction and trial duration. We identified k = 78 studies each contributing multiple sub-samples and performed 23 meta-analyses for combinations of emotion regulation strategy and psychophysiological measure. Overall, results showed that effects of reappraisal and suppression on autonomic measures were highly inconsistent across studies with rather small mean effect sizes. Electromyography (startle and corrugator activity) showed medium effect sizes that were consistent across studies. Our findings highlight the diversity as well as the low level of standardization and comparability of research in this area. Significant moderation of effects by study design, trial duration, and control condition emphasizes the need for better standardization of methods. In addition, the small mean effect sizes resulting from our analyses on autonomic measures should be interpreted with caution. Findings corroborate the importance of multi-channel approaches.

Dissociation proneness and pain hyposensitivity in current and remitted borderline personality disorder

BACKGROUND

Stress-related dissociation has been shown to negatively co-vary with pain perception in current borderline personality disorder (cBPD). While remission of the disorder (rBPD) is associated with normalized pain perception, it remains unclear whether dissociation proneness is still enhanced in this group and how this feature interacts with pain sensitivity.

METHODS

Twenty-five cBPD patients, 20 rBPD patients and 24 healthy controls (HC) participated in an experiment using the script-driven imagery approach. We presented a personalized stressful and neutral narrative. After listening to the scripts, dissociation and heat pain thresholds (HPT) were assessed.

RESULTS

Compared to HC, cBPD patients showed enhanced dissociation and exhibited significantly enhanced HPT in the neutral condition, whereas rBPD participants were in between. After listening to the stress script, both clinical groups exhibited enhanced dissociation scores. Current BPD participants responded with significantly higher HPT, whereas rBPD only showed a trend in the same direction. However, both BPD groups showed significantly increased HPT compared to the HC in the stress condition, but did not differ from each other. Dissociation proneness correlated significantly positively with pain hyposensitivity only in cBPD.

CONCLUSION

Dissociation proneness is enhanced in both BPD groups. This feature is clearly positively related to pain hyposensitivity in cBPD, but not in rBPD. However, the data indicate that stress causes the pain perception in rBPD to drift away from that obtained in HC. These results highlight the volatile state of BPD remission and might have important implications for the care of BPD patients in the remitted stage.

SIGNIFICANCE

Both current (cBPD) and remitted borderline personality disorder (rBPD) patients show enhanced proneness to dissociation. This feature is significantly linked with pain hyposensitivity in cBPD in a paradigm that induces stress using a script-driven imagery approach, whereas this connection cannot be observed in rBPD. However, in the stress compared to the neutral condition, rBPD participants also show pain hyposensitivity compared to healthy controls. This study provides new insights into the pain processing mechanisms of BPD and its remission.

Heart and brain: Cortical representation of cardiac signals is disturbed in borderline personality disorder, but unaffected by oxytocin administration

BACKGROUND

Emotional dysregulation, a core feature of borderline personality disorder (BPD) has recently been linked to deficits in the cortical representation of bodily signals. Oxytocin modulates the salience of external social cues. However, its role in interoception is still not fully understood. The aim of the current study was to replicate reduced heartbeat-evoked potentials (HEPs) as a marker for the cortical representation of cardiac signals in BPD and to explore potential effects of oxytocin on HEP amplitude.

METHODS

Fifty-three medication-free women with a DSM-IV diagnosis of BPD and sixty healthy female controls (HCs) participated in the study. In a randomized, double-blind placebo-controlled trial, participants self-administered either 24 I.U. of oxytocin or placebo and took part in a 5-minute resting-state electrocardiogram (ECG) with parallel electroencephalogram (EEG) measurement. In addition, emotional dysregulation and BPD symptomatology were assessed with self-report questionnaires.

RESULTS

Patients with BPD had significantly lower mean HEP amplitudes than HCs. Furthermore, HEP amplitudes were negatively correlated with emotional dysregulation in the whole sample. However, oxytocin had no significant effect on HEP amplitude.

LIMITATIONS

Only female participants were investigated and no clinicial controls were included.

CONCLUSIONS

This is the first replication from an independent sample showing a reduced cortical representation of cardiac signals in BPD patients. This, together with other body-related symptoms, suggests deficits in the processing of bodily signals, which seem to be associated with emotional dysregulation. Whether oxytocin influences HEP during emotion regulation tasks needs to be investigated in future studies.

Oxytocin Normalizes Approach-Avoidance Behavior in Women With Borderline Personality Disorder

Background: Interpersonal deficits are a core symptom of borderline personality disorder (BPD), which could be related to increased social threat sensitivity and a tendency to approach rather than avoid interpersonal threats. The neuropeptide oxytocin has been shown to reduce threat sensitivity in patients with BPD and to modify approach-avoidance behavior in healthy volunteers. Methods: In a randomized, double-blind placebo-controlled between-subject design, 53 unmedicated women with BPD and 61 healthy women participated in an approach-avoidance task 75 min after intranasal substance administration (24 IU of oxytocin or placebo). The task assesses automatic approach-avoidance tendencies in reaction to facial expressions of happiness and anger. Results: While healthy participants responded faster to happy than angry faces, the opposite response pattern, that is, faster reactions to angry than happy faces, was found in patients with BPD. In the oxytocin condition, the "congruency effect" (i.e., faster avoidance of facial anger and approach of facial happiness vice versa) was increased in both groups. Notably, patients with BPD exhibited a congruency effect toward angry faces in the oxytocin but not in the placebo condition. Conclusions: This is the second report of deficient fast, automatic avoidance responses in terms of approach behavior toward interpersonal threat cues in patients with BPD. Intranasally administered oxytocin was found to strengthen avoidance behavior to social threat cues and, thus, to normalize fast action tendencies in BPD. Together with the previously reported oxytocinergic reduction of social threat hypersensitivity, these results suggest beneficial effects of oxytocin on interpersonal dysfunctioning in BPD.

Intact Classical Fear Conditioning to Interpersonally Threatening Stimuli in Borderline Personality Disorder

Threat hypersensitivity is regarded as a central mechanism of deficient emotion regulation, a core feature of patients with borderline personality disorder (BPD). Here, we employed a classical fear-conditioning protocol in which interpersonally threatening, interpersonally non-threatening, and non-social (neutral) visual stimuli were predictive of an aversive auditory stimulus in a sample of 23 medication-free adult female patients with BPD and 21 age- and IQ-matched healthy women. The results did not confirm the hypothesized enhanced and prolonged conditioned skin conductance responses (SCR) and subjective stress and expectancy ratings to interpersonally threatening stimuli in patients with BPD compared to healthy women. Patients with BPD generally expected the aversive stimulus more often irrespective of stimulus category and conditioning. Furthermore, patients with BPD showed larger conditioned SCR to interpersonally non-threatening and neutral than interpersonally threatening stimuli, while interpersonally threatening stimuli elicited higher SCR compared to non-threatening or neutral stimuli in healthy controls. Together with previous studies, the results suggest no alterations in fear conditioning to generally aversive stimuli in BPD. Further studies using stimuli with BPD-specific topics, such as abandonment or rejection, and/or to investigate more interpersonal forms of learning, such as observational or instructed conditioning, are urgently needed to further elucidate the mechanisms involved in the etiology and maintenance of threat hypersensitivity in BPD.

Deficient Amygdala Habituation to Threatening Stimuli in Borderline Personality Disorder Relates to Adverse Childhood Experiences

BACKGROUND

Heightened amygdala response to threatening cues has been repeatedly observed in borderline personality disorder (BPD). A previous report linked hyperactivation to deficient amygdala habituation to repeated stimuli, but the biological underpinnings are incompletely understood.

METHODS

We examined a sample of 120 patients with BPD and 115 healthy control subjects with a well-established functional magnetic resonance imaging emotional face processing task to replicate the previously reported amygdala habituation deficit in BPD and probed this neural phenotype for associations with symptom severity and early social risk exposure.

RESULTS

Our results confirm a significant reduction in amygdala habituation to repeated negative stimuli in BPD (p_FWE = .015, peak-level familywise error [FWE] corrected for region of interest). Post hoc comparison and regression analysis did not suggest a role for BPD clinical state (p_FWE > .56) or symptom severity (p_FWE > .45) for this phenotype. Furthermore, deficient amygdala habituation was significantly related to increased exposure to adverse childhood experiences (p_FWE = .013, region of interest corrected).

CONCLUSIONS

Our data replicate a prior report on deficient amygdala habituation in BPD and link this neural phenotype to early adversity, a well-established social environmental risk factor for emotion dysregulation and psychiatric illness.

Enhanced pain modulation capacity among individuals with borderline personality disorder: A possible mechanism underlying their hypoalgesia

BACKGROUND

Ample evidence suggests that individuals with borderline personality disorder (BPD) exhibit hyposensitivity to pain. Since the underlying mechanism of the pain hyposensitivity is unknown, we tested here for the first time whether this hyposensitivity is pain specific or exists also for innocuous sensation, and whether it is associated with enhanced descending pain modulation capabilities.

METHODS

Participants were 55 women; 22 patients with BPD and 33 matched healthy controls. Testing included the measurement of warmth sensation threshold (WST), heat-pain threshold (HPT), pain adaptation, conditioned pain modulation (CPM) and temporal summation of heat-pain (TSP). The level of dissociation was also evaluated.

RESULTS

Women with BPD had higher WST and HPT compared with healthy controls. Moreover, women with BPD had greater magnitude of pain adaptation and CPM as well as higher dissociation level compared to controls. In neither the BPD nor the control group did WST and HPT correlate with pain adaptation, CPM or dissociation. In the BPD group only, HPT inversely correlated with the magnitude of TSP.

CONCLUSIONS

Women with BPD present generalized hyposensitivity to both innocuous and noxious stimuli. Furthermore, women with BPD exhibit more efficient pain inhibition capabilities than healthy controls. While efficient pain modulation may underlie pain hyposensitivity in BPD, both traits may exist independently from each other, or may be moderated by another factor such as dissociation.

SIGNIFICANCE

On the basis of testing pronociceptive and antinociceptive components among individuals with BPD and healthy controls, this study reveals enhanced ability to inhibit pain among woman with borderline personality disorder (BPD) which may underlie hyposensitivity to both noxious and innocuous stimuli and perhaps also self-injurious behaviour among these individuals. The study contributes novel information on possible mechanisms involved in BPD manifestations.

Improved emotion regulation after neurofeedback: A single-arm trial in patients with borderline personality disorder

Real-time functional magnetic resonance imaging (fMRI) neurofeedback training of amygdala hemodynamic activity directly targets a neurobiological mechanism, which contributes to emotion regulation problems in borderline personality disorder (BPD). However, it remains unknown which outcome measures can assess changes in emotion regulation and affective instability, associated with amygdala downregulation in a clinical trial. The current study directly addresses this question. Twenty-four female patients with a DSM-IV BPD diagnosis underwent four runs of amygdala neurofeedback. Before and after the training, as well as at a six-weeks follow-up assessment, participants completed measures of emotion dysregulation and affective instability at diverse levels of analysis (verbal report, clinical interview, ecological momentary assessment, emotion-modulated startle, heart rate variability, and fMRI). Participants were able to downregulate their amygdala blood oxygen-dependent (BOLD) response with neurofeedback. There was a decrease of BPD symptoms as assessed with the Zanarini rating scale for BPD (ZAN-BPD) and a decrease in emotion-modulated startle to negative pictures after training. Further explorative analyses suggest that patients indicated less affective instability, as seen by lower hour-to-hour variability in negative affect and inner tension in daily life. If replicated by an independent study, our results imply changes in emotion regulation and affective instability for several systems levels, including behavior and verbal report. Conclusions are limited due to the lack of a control group. A randomized controlled trial (RCT) will be needed to confirm effectiveness of the training.

Heart rate variability during a cognitive reappraisal task in female patients with borderline personality disorder: the role of comorbid posttraumatic stress disorder and dissociation

BACKGROUND

Emotion dysregulation is a core feature of borderline personality disorder (BPD), which often co-occurs with posttraumatic stress disorder (PTSD). Difficulties in emotion regulation (ER) have been linked to lower high-frequency heart rate variability (HF-HRV), a measure of autonomous nervous system functioning. However, previous research on vagally-mediated heart rate in BPD revealed heterogeneous findings and the effects of comorbid PTSD and dissociation on HF-HRV are not yet completely understood. This study aim to investigate HF-HRV during resting-state and an ER task in female BPD patients with comorbid PTSD (BPD + PTSD), patients without this comorbidity (BPD), and healthy controls (HC).

METHODS

57 BPD patients (BPD: n = 37, BPD + PTSD: n = 20) and 27 HC performed an ER task with neutral, positive, and negative images. Participants were instructed to either attend these pictures or to down-regulate their upcoming emotions using cognitive reappraisal. Subjective arousal and wellbeing, self-reported dissociation, and electrocardiogram data were assessed.

RESULTS

Independent of ER instruction and picture valence, both patient groups (BPD and BPD + PTSD) reported higher subjective arousal and lower wellbeing; patients with BPD + PTSD further exhibited significantly lower HF-HRV compared with the other groups. Higher self-reported state dissociation predicted higher HF-HRV during down-regulating v. attending negative pictures in BPD + PTSD.

CONCLUSIONS

Findings suggest increased emotional reactivity to negative, positive, and neutral pictures, but do not provide evidence for deficits in instructed ER in BPD. Reduced HF-HRV appears to be particularly linked to comorbid PTSD, while dissociation may underlie attempts to increase ER and HF-HRV in BPD patients with this comorbidity.

Whole-brain functional connectivity during script-driven aggression in borderline personality disorder

OBJECTIVE

Intense anger and anger-related aggression are frequently reported by patients with borderline personality disorders (BPD). Recent results suggest that anger-related aggression and its control is associated with a complex interplay of different neural systems in BPD. To further investigate this, we complement standard activation and seed-based connectivity analyses by examining whole-brain changes in functional connectivity during anger and reactive aggression in BPD.

METHODS

We reanalyzed functional MRI data from 33 women with BPD, all of them fulfilling BPD criterion 8, "anger proneness", according to DSM-IV, and 30 healthy women. Subjects performed a script-driven imagery task consisting of four phases: baseline, anger-induction by a narrative of interpersonal rejection, a narrative of directing physical aggression towards others, and relaxation. We used a data-driven, spatially constrained spectral clustering approach to parcellate the brain into 200 regions. For each script-phase and subject, we computed the full connectivity matrix using wavelet coefficient correlations in the 0.05-0.10 Hz range. We calculated the individual increase in connectivity from baseline to the anger-induction and physical aggression phases by subtracting the corresponding connectivity matrices per subject, as well as the increase and decrease from the anger-induction to the aggression phase. We then applied permutation-based sampling to determine a combined threshold on the strength of individual connections and the size of the discovered networks for these difference matrices.

RESULTS

We discovered a single, large network showing a significantly stronger increase in connectivity from baseline to the aggression phase in female patients with BPD compared to healthy women. This network consisted of regions in the anterior and posterior cingulate cortex, precuneus, dorsomedial prefrontal cortex, superior and middle temporal gyrus, hippocampus, insula, ventrolateral and dorsolateral prefrontal cortex, superior parietal lobe, thalamus, precentral and postcentral gyrus, caudate, pallidum, cerebellum, middle occipital lobe, lingual gyrus, calcarine sulcus, and fusiform gyrus. Hub regions with highest node centrality were found in the right caudate and left thalamus. We found no significant differences for the increase of connectivity from baseline to anger-induction, as well as for the increase or decrease from the anger-induction to the aggression phase.

CONCLUSIONS

We identified a large network showing a significantly stronger increase in connectivity from baseline to the aggression phase in female patients with BPD compared to healthy women. The regions constituting this network belong to four previously described functional networks: The frontoparietal cognitive control network, the extended default mode network, the visual system, and the motor system. This stronger increase in connectivity between regions of different functional brain systems associated with cognitive control of behavior, socio-affective and self-referential thinking, as well as salience processing and emotion regulation, visual perception, and action is mediated via hubs in the thalamus and caudate, i.e., core components of the thalamocorticostriatal motor loop essential for action selection and initiation. These findings suggest increased interaction of prefrontal cognitive control processes with thalamocorticostriatal action-selection processes in female patients with BPD during the processing of aggressive action impulses, which are facilitated by states of high emotional salience and associated processes of self-referential and social processing, and ineffective emotion regulation.

Effects of a Painful Stimulus on Stress Regulation in Male Patients With Borderline Personality Disorder: A Pilot Study

Pain processing in relation to stress has so far not been investigated in male patients with borderline personality disorder (BPD). This experimental pilot study examined 17 male BPD patients and 20 male healthy controls (HCs) to assess the effects of a pain stimulus on arousal, aggression, pain (ratings), and heart rate. At baseline, BPD patients showed significantly higher arousal and aggression; however, there was no significant difference in heart rate compared to the HC group. Following stress induction, a noninvasive mechanical pain stimulus was applied. No significant differences in pain ratings or heart rates were found between the groups. For arousal, a significantly stronger decrease was revealed in the BPD group compared to the HC group (t = 2.16, p = .038). Concerning aggression, the BPD group showed a significantly greater decrease after the pain stimulus than the HC group (t = 3.25, p = .002). This data showed that nonsuicidal self-injury can reduce arousal and aggression in male BPD.

Impact of infant crying on mothers with a diagnosis of borderline personality disorder: A qualitative study

Mothers with borderline personality disorder (BPD) and their infants often have compromised relationships. To further understand the complexities, this study explored (a) the experiences of mothers with BPD in response to infant crying and (b) how these parenting responses impact on mothers' interpersonal functioning with significant others. Six mothers with clinical BPD were recruited from a mother-baby psychiatric unit and interviewed using an interpretative phenomenological analysis (IPA) approach. Transcripts of the semistructured interviews were coded for themes and subthemes. Dominant themes revealed that mothers with BPD entered motherhood in a psychologically fragile state, hypersensitive to experiencing intense physiological-emotional pain and cognitive chaos in response to infant crying. Automatic maladaptive flight-fright responses including suicide attempts were common. A novel theme revealed some mothers' split identity, and only the "mother" part could attend to infant crying. Finally, the data provided an understanding of the detrimental domino effect on close family. Mothers also highlighted gaps in accessibility of current mental health services and parenting programs, and their desire to prevent the intergenerational transmission of attachment problems and BPD symptoms to offspring. Clinical implications include antenatal BPD screening, psychoeducation about infant crying, and greater access for programs supporting the whole family to improve outcomes.

EEG-vigilance regulation in Borderline Personality Disorder

BACKGROUND

Borderline Personality Disorder (BPD) is characterized by emotional instability, impulsivity, disturbed cognition, sleeplessness and states of high inner tension. Altered arousal regulation which is regarded as a higher domain of functioning according to the research domain criteria of the NIMH and which has previously been reported in several psychiatric disorders, such as mania or major depression could be involved in these features of BPD.

METHODS

40 unmedicated patients with BPD and 42 matched healthy volunteers participated in a twenty minute resting-state EEG measurement with closed eyes. EEG-vigilance regulation was assessed with VIGALL2.0 (Vigilance Algorithm Leipzig), which allows a classification of consecutive 1-s segments in different vigilance stages ranging from high alertness/relaxed wakefulness (stages 0, A1, A2, A3) to drowsiness (B1, B2/3) and sleep onset (C).

RESULTS

Across 20 min, both groups showed a similar decline from higher to lower vigilance stages, but patients with BPD remained in higher stages of vigilance compared to healthy volunteers across the whole measurement (p = .013). Contrary to this, pre-experimental ratings indicated enhanced subjective sleepiness but no differences in self-reported sleep quantity in the previous night in patients with BPD compared to healthy volunteers.

CONCLUSIONS

The results of an elevated arousal regulation (in combination with increased subjective sleepiness) might reflect several symptoms, such as aversive inner tension and impoverished sense of self in patients with BPD. As arousal is linked to the noradrenergic system, further investigations in this field seem to be promising.

Self-reported impulsivity in women with borderline personality disorder: the role of childhood maltreatment severity and emotion regulation difficulties

BACKGROUND

Childhood maltreatment, such as severe emotional, physical, and sexual abuse and neglect, has been linked to impulse control problems and dysfunctional emotional coping. In borderline personality disorder (BPD), a history of childhood maltreatment may worsen difficulties in emotion regulation, which may in turn give rise to impulsive behaviours. The aim of this self-report study was to investigate associations between childhood maltreatment severity, emotion regulation difficulties, and impulsivity in women with BPD compared to healthy and clinical controls.

METHODS

Sixty-one female patients with BPD, 57 clinical controls (CC, women with Attention Deficit Hyperactivity Disorder and/or Substance Use Disorder, without BPD), and 60 female healthy controls (HC) completed self-report scales on childhood trauma (Childhood Trauma Questionnaire, CTQ), difficulties in emotion regulation (Difficulties in Emotion Regulation Scale, DERS), and impulsivity (UPPS Impulsive Behaviour Scale). A conditional process analysis was performed to investigate whether emotion dysregulation statistically mediated the effect of childhood maltreatment severity on impulsivity depending on group (BPD vs. CC vs. HC).

RESULTS

Childhood maltreatment, particularly emotional maltreatment, was positively associated with impulsivity and emotion regulation difficulties across all groups. Difficulties in emotion regulation statistically mediated the effect of childhood maltreatment on impulsivity in BPD, but not in the other groups.

CONCLUSION

In the context of current conceptualizations of BPD and previous research, findings suggest that problems with emotion regulation may be related to a history of childhood maltreatment, which may in turn enhance impulsivity. Targeting emotion dysregulation in psychotherapy and discussing it in relation to childhood maltreatment can help decreasing impulsive behaviors in individuals with BPD. Given the correlational design of our study which does not allow causal conclusions, future studies have to employ prospective, experimental designs and include larger sample sizes to corroborate associations between childhood maltreatment, emotion dysregulation, and impulsivity.

The Sound and Face of Others: Vocal Priming Effects on Facial Emotion Processing in Posttraumatic Stress Disorder

INTRODUCTION

Facial expressions and vocal intonation are key signals in the communication of emotions. Individuals with posttraumatic stress disorder (PTSD) are known to show an impaired perception of facial emotions. So far, research on multimodal emotional stimuli or the priming effects on emotion processing has been absent in PTSD. Therefore, we conducted a study to investigate the influence of vocal priming on facial emotion processing and classification in PTSD using electroencephalography.

METHODS

Twenty-one women with PTSD compared to 28 healthy women were asked to classify emotion-morphed faces with predominantly angry, ambiguous, or predominantly happy expressions primed by either an angry or a happy voice. Responses and reaction times as well as the N170, a component reflecting configural face processing, were analyzed.

RESULTS

Patients with PTSD were slower in classifying emotional faces that were primed by either an angry or happy voice compared to the healthy controls (HCs; η2 = 0.14). Additionally, patients with PTSD were faster in classifying facial expressions after angry compared to happy vocal primes (η2 = 0.14). HCs did not show this effect. Correlation analyses revealed positive associations between emotion (dys-)regulation and reaction times in patients with PTSD but not in HCs (r = 0.64-0.76). Furthermore, patients with PTSD showed greater N170 amplitudes for predominantly angry and ambiguous faces than HCs (η2 = 0.07).

CONCLUSION

Data suggest that patients with PTSD experience more difficulties when processing complex social stimuli than HCs. The altered processing of complex social-emotional signals could amplify PTSD symptoms, thus qualifying as an explicit therapy target.

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.

Out of control? Acting out anger is associated with deficient prefrontal emotional action control in male patients with borderline personality disorder

Difficulty in anger control and anger-related aggressive outbursts against others are frequently reported by patients with borderline personality disorder (BPD). Although male sex is a known predictor for aggression, hardly any study has addressed the neural correlates of deficient anger control in male patients with BPD. Building on previous reports in female BPD, we investigated the involvement of lateral antero- and dorsal prefrontal cortex in the control of fast emotional actions and its relation to self-reported tendencies to act out anger. 15 medication-free male patients with BPD and 25 age- and intelligence-matched healthy men took part in a social Approach-Avoidance task in the MR-scanner. This task allows the measurement of neural correlates underlying the control of fast behavioral tendencies to approach happy and avoid angry faces. Hypothesis-driven region-of-interest and exploratory whole brain analyses were used to test for activations of antero- and dorsolateral prefrontal regions and their relation with the amygdala during emotional action control as well as their association with self-reported anger out in male patients with BPD and healthy volunteers. Male patients with BPD showed reduced anterolateral prefrontal activations during emotional action control compared to healthy volunteers. Furthermore, anger out was negatively related to antero- and dorsolateral prefrontal activations, while it was positively related to amygdala activity in male patients with BPD. The current results suggest the involvement of antero- and dorsolateral prefrontal regions in controlling and overriding fast emotional actions. Deficits in lateral prefrontal emotion control seem to be a common neural mechanism underlying anger-related aggression. This article is part of the Special Issue entitled 'Current status of the neurobiology of aggression and impulsivity'.

Change in Emotional and Theory of Mind Processing in Borderline Personality Disorder: A Pilot Study

Changes in emotional processing (EP) and in theory of mind (TOM) are central across treatment approaches for patients with borderline personality disorder (BPD). Although the assessment of EP relies on the observation of a patient's self-criticism in a two-chair dialogue, an individual's TOM assessments is made based on responses to humorous stimuli based on false beliefs. For this pilot study, we assessed eight patients with BPD before and after a 3-month-long psychiatric treatment, using functional magnetic resonance imaging and behavioral tasks. We observed arousal increase within the session of the two-chair dialogue (d = 0.36), paralleled by arousal decrease between sessions (d = 0.80). We found treatment-associated trends for neural activity reduction in brain areas central for EP and TOM. Our exploratory findings using an integrative assessment procedure of changes in EP and TOM point toward evidence for treatment effects at the brain systems level related to behavioral modulation.