Emotion processing in borderline personality disorders

Differences between psychopathy and other personality disorders: evidence from neuroimaging

ICD-10 and DSM-IV-TR diagnostic guidelines do not list psychopathy as a distinct psychiatric entity. However, there are significant overlaps between psychopathy and DSM-IV-TR Cluster B personality disorders. Neuroimaging studies implicate deficits in structure and function of frontal and limbic regions in this group of personality disorders, while highlighting both distinctions and overlaps between syndromes. Here, these data are reviewed and implications for diagnosis and clinical practice are discussed.

Surviving moment to moment: The experience of living in a state of ambivalence for those with recurrent suicide attempts

OBJECTIVE

This qualitative study aimed to capture the experience of living in the ambivalent space between life and death for adults with recurrent suicide attempts (RSA). It sought to expand upon an earlier study that explored the processes involved in transitioning away from RSA among adults, which revealed that occupying this ambivalent space is a crucial part of this process.

DESIGN

Interpretive phenomenological analysis (IPA) was used. This methodology was designed to explore the lived experiences and meaning making and enabled interpretation of the multidimensional subjective experiences of RSA participants.

METHODS

In-depth semi-structured interviews were conducted with eight adult women with a history of RSA who had participated in a therapeutic intervention at the research site (Skills for Safer Living: A Psychosocial/Psychoeducational Intervention for People with Recurrent Suicide Attempts [SfSL/PISA]). The six stages of IPA were followed to analyse the interview data.

RESULTS

Analysis revealed the superordinate theme, 'surviving moment to moment', which refers to a precarious state of making decisions about one's life and destiny on a moment-to-moment basis without clear commitment to either life or death. Two subordinate themes were identified: 'deciding not to die in the moment' when the participants were more invested in dying than living and 'deciding to live in the moment' when they were more invested in living than dying.

CONCLUSION

The study illuminated the complex process of making decisions about ones' destiny on a moment-to-moment basis. It revealed the torment experienced when occupying this state, while paradoxically, also revealing how indecision about life and death provided a lifeline opportunity for those with RSA. Clinicians who recognize the subtle distinctions associated with this in-between state can tailor their interventions accordingly.

PRACTITIONER POINTS

Surviving moment to moment is characterized by a state of emotional flux and uncertainty about one's destiny, where the person has not fully committed to either life or death. Within this state, there are two interlinked subprocesses, whereby the person is leaning more towards death or life. A critical feature in working with this client group is to recognize their ambiguity and the fragility and temporality of their decisions about their destiny. The practitioner has an opportunity to be a catalyst in the momentum towards life by demonstrating understanding of this survival struggle and tailoring intervention to fit with the nuanced processes within this state.

Reconsidering Emotion Dysregulation

This article aims to review the concept of emotion dysregulation, focusing on issues related to its definition, meanings and role in psychiatric disorders. Articles on emotion dysregulation published until May 2016 were identified through electronic database searches. Although there is no agreement about the definition of emotion dysregulation, the following five overlapping, not mutually exclusive dimensions of emotion dysregulation were identified: decreased emotional awareness, inadequate emotional reactivity, intense experience and expression of emotions, emotional rigidity and cognitive reappraisal difficulty. These dimensions characterise a number of psychiatric disorders in various proportions, with borderline personality disorder and eating disorders seemingly more affected than other conditions. The present review contributes to the literature by identifying the key components of emotion dysregulation and by showing how these permeate various forms of psychopathology. It also makes suggestions for improving research endeavours. Better understanding of the various dimensions of emotion dysregulation will have implications for clinical practice. Future research needs to address emotion dysregulation in all its multifaceted complexity so that it becomes clearer what the concept encompasses.

Emotion Regulation in Borderline Personality Disorder: An Experimental Investigation of the Effects of Instructed Acceptance and Suppression

Difficulties with emotion regulation are central to borderline personality disorder (BPD). Recent research suggests that avoidance of emotions in general, and emotion suppression specifically, may be commonly used among those who meet criteria for the disorder. Contemporary behavioral interventions for BPD incorporate cognitive and behavioral skills to increase emotional experiencing and acceptance while decreasing behaviors that function to escape or avoid from emotions. Few studies, however, have experimentally examined the effects of instructed emotion suppression and acceptance in BPD. The present study examined the effects of instructed use of different emotion regulation strategies on emotions, psychophysiology, and behavior in BPD. Participants with BPD, major depressive disorder (MDD), and nonpsychiatric controls (N = 193) were randomly assigned to either suppress or accept emotions during an audio recording of a social rejection scenario, and completed a behavioral measure of distress tolerance. BPD participants exhibited greater heart rate variability in the acceptance (vs. suppression) condition; this pattern was not evident within the other groups. These results suggest that deliberate use of acceptance-based emotion regulation strategies may have unique physiological effects among individuals with BPD.

Different aspects of emotional intelligence of borderline personality disorder

OBJECTIVES

The present study investigated deficiencies in different components of emotional intelligence in borderline personality disorder (BPD).

METHOD

The Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) and the Emotional Quotient Inventory (EQ-i) were used to assess EI dimensions. BPD patients (N = 85; 69 women; M = 33.6 years) were compared with Cluster C personality disorder (PD) patients (N = 39; 23 women; M = 36.6 years) and nonpatients (N = 69; 44 women; M = 35.6 years).

RESULTS

Compared to the Cluster C PD patients and the nonpatient group, BPD patients displayed only deficits in their ability to understand emotions as measured with the Mayer-Salovey-Caruso Emotional Intelligence Test. The Emotional Quotient Inventory only revealed deficits in stress management in BPD patients compared to Cluster C PD patients.

CONCLUSIONS

Our findings suggest that BPD patients have the ability to regulate emotions effectively, but they subjectively experience deficits in emotion regulation and therefore may not use this ability when they need it.

Facial emotion recognition and borderline personality pathology

The impact of borderline personality pathology on facial emotion recognition has been in dispute; with impaired, comparable, and enhanced accuracy found in high borderline personality groups. Discrepancies are likely driven by variations in facial emotion recognition tasks across studies (stimuli type/intensity) and heterogeneity in borderline personality pathology. This study evaluates facial emotion recognition for neutral and negative emotions (fear/sadness/disgust/anger) presented at varying intensities. Effortful control was evaluated as a moderator of facial emotion recognition in borderline personality. Non-clinical multicultural undergraduates (n = 132) completed a morphed facial emotion recognition task of neutral and negative emotional expressions across different intensities (100% Neutral; 25%/50%/75% Emotion) and self-reported borderline personality features and effortful control. Greater borderline personality features related to decreased accuracy in detecting neutral faces, but increased accuracy in detecting negative emotion faces, particularly at low-intensity thresholds. This pattern was moderated by effortful control; for individuals with low but not high effortful control, greater borderline personality features related to misattributions of emotion to neutral expressions, and enhanced detection of low-intensity emotional expressions. Individuals with high borderline personality features may therefore exhibit a bias toward detecting negative emotions that are not or barely present; however, good self-regulatory skills may protect against this potential social-cognitive vulnerability.

Borderline Personality Disorder and the Effects of Instructed Emotional Avoidance or Acceptance in Daily Life

This study examined the effects of avoidance- versus acceptance-oriented emotion regulation instructions among individuals with borderline personality disorder (BPD; n = 48), major depressive disorder (MDD; n = 54), and non-psychiatric controls (NPC; n = 50) using ecological momentary assessment. Participants were randomly assigned to either accept or avoid negative emotions, and monitored their moods, urges, and distress tolerance several times per day over 6 days. Avoidance instructions resulted in reduced negative affect and urges for maladaptive behaviors uniquely among BPD participants. Together with past research, and consistent with treatment approaches emphasizing the short-term use of skills to avoid or distract from emotions (e.g., DBT; Linehan, 1993b, 2015), these findings suggest that avoidance of negative emotions may have temporary benefits for individuals with BPD. Acceptance-oriented strategies may take longer or may require more extensive training to be beneficial for emotional functioning in everyday life in BPD.

An ecological momentary assessment investigation of complex and conflicting emotions in youth with borderline personality disorder

Non-suicidal self-injury (NSSI) is a prevalent behaviour among people with borderline personality disorder (BPD) but many aspects of the emotional changes that trigger and maintain this behaviour are unknown. This study examines the relationships between NSSI and the number of negative ('negative complex') and opposing valence ('conflicting') emotions. One hundred and seven youth (aged 15-25 years) with first-presentation BPD were assessed using a combination of self-report and ecological momentary assessment to investigate trait levels of emotional acceptance and in vivo changes in the number of negative complex and conflicting emotions before and after self-injurious thoughts and behaviours. Multilevel modelling revealed that changes in the number of negative complex emotions mirrored distress levels before and after self-injurious thoughts and behaviours, approximating a quadratic curve. Increases in the number of negative complex emotions reported prior to self-injurious thoughts and behaviours were associated with lower acceptance of negative emotions. These findings indicate that the number of negative emotions experienced contributes to distress prior to engagement in NSSI. The relationship between non-acceptance of negative emotions and negative complex emotions prior to NSSI suggests that improved emotional awareness and acceptance should be a focus for early interventions aimed at reducing self-injury.

A Meta-analysis on the Association Between Emotional Awareness and Borderline Personality Pathology

Theories on borderline personality pathology (BPP) suggest that characteristic emotional dysregulation is due to low levels of emotional awareness or alexithymia. This study is the first meta-analysis to systematically review and analyze the evidence. A systematic search of the literature was performed using PsycInfo, Web of Science/MEDLINE, and Scopus. The term "borderline personality disorder" was searched for in conjunction with "emotional awareness," "emotional self-awareness," "emotion recognition," "alexithymia," "emotional processing," "emotional granularity," "emotional intelligence," or "emotion regulation." All references in the included studies were reviewed for additional relevant articles. Thirty-nine studies were then evaluated in a random effects meta-analysis to assess the association between BPP and emotional awareness. An overall moderate positive association between BPP and emotional awareness was significant (r = 0.359; 95% CI [0.283, 0.431]; Z = 8.678; p < 0.001) along with high heterogeneity (Q(38) = 456.7; p < .001; I² = 91.7%). Studies comparing borderline personality disorder to healthy controls yielded a strong association (r = 0.518; 95% CI [0.411, 0.611]). No significant difference was found between studies using instruments for emotional awareness and those using alexithymia instruments. The strongest associations with regard to aspects of alexithymia were found for difficulties in identifying and describing emotions rather than externally oriented thinking. The results corroborate a moderate relationship between low emotional awareness and BPP. However, the mono-method self-report used in almost all studies is found problematic and precludes drawing definite conclusions. Since leading psychotherapeutic treatments strongly focus on increasing emotional awareness, future research should address this issue and further examine to what extent low levels of emotional awareness, particularly alexithymia, can be treated.

Core, social and moral disgust are bounded: A review on behavioral and neural bases of repugnance in clinical disorders

Disgust is a multifaceted experience that might affect several aspects of life. Here, we reviewed research on neurological and psychiatric disorders that are characterized by abnormal disgust processing to test the hypothesis of a shared neurocognitive architecture in the representation of three disgust domains: i) personal experience of 'core disgust'; ii) social disgust, i.e., sensitivity to others' expressions of disgust; iii) moral disgust, i.e., sensitivity to ethical violations. Our review provides some support to the shared neurocognitive hypothesis and suggests that the insula might be the "hub" structure linking the three domains of disgust sensitivity, while other brain regions may subserve specific facets of the multidimensional experience. Our review also suggests a role of serotonin core and moral disgust, supporting "neo-sentimentalist" theories of morality, which posit a causal role of affect in moral judgment.

Hyper-modulation of brain networks by the amygdala among women with Borderline Personality Disorder: Network signatures of affective interference during cognitive processing

Emotion dysregulation is a core characteristic of patients with Borderline Personality Disorder (BPD), and is often attributed to an imbalance in fronto-limbic network function. Hyperarousal of amygdala, especially in response to negative affective stimuli, results in affective interference with cognitive processing of executive functions. Clinical consequences include the impulsive-aggression, suicidal and self-injurious behaviors which characterize BPD. Dysfunctional interactions between amygdala and its network targets have not been well characterized during cognitive task performance. Using psychophysiological interaction analysis (PPI), we mapped network profiles of amygdala interaction with key regulatory regions during a Go No-Go task, modified to use negative, positive and neutral Ekman faces as targets. Fifty-six female subjects, 31 BPD and 25 healthy controls (HC), completed the affectively valenced Go No-Go task during fMRI scanning. In the negative affective condition, the amygdala exerted greater modulation of its targets in BPD compared to HC subjects in Rt. OFC, Rt. dACC, Rt. Parietal cortex, Rt. Basal Ganglia, and Rt. dlPFC. Across the spectrum of affective contrasts, hypermodulation in BPD subjects observed the following ordering: Negative > Neutral > Positive contrast. The amygdala seed exerted modulatory effects on specific target regions important in processing response inhibition and motor impulsiveness. The vulnerability of BPD subjects to affective interference with impulse control may be due to specific network dysfunction related to amygdala hyper-arousal and its effects on prefrontal regulatory regions such as the OFC and dACC.

Facing the Problem: Impaired Emotion Recognition During Multimodal Social Information Processing in Borderline Personality Disorder

Previous research has revealed alterations and deficits in facial emotion recognition in patients with borderline personality disorder (BPD). During interpersonal communication in daily life, social signals such as speech content, variation in prosody, and facial expression need to be considered simultaneously. We hypothesized that deficits in higher level integration of social stimuli contribute to difficulties in emotion recognition in BPD, and heightened arousal might explain this effect. Thirty-one patients with BPD and thirty-one healthy controls were asked to identify emotions in short video clips, which were designed to represent different combinations of the three communication channels: facial expression, speech content, and prosody. Skin conductance was recorded as a measure of sympathetic arousal, while controlling for state dissociation. Patients with BPD showed lower mean accuracy scores than healthy control subjects in all conditions comprising emotional facial expressions. This was true for the condition with facial expression only, and for the combination of all three communication channels. Electrodermal responses were enhanced in BPD only in response to auditory stimuli. In line with the major body of facial emotion recognition studies, we conclude that deficits in the interpretation of facial expressions lead to the difficulties observed in multimodal emotion processing in BPD.

Perception of Verbal and Nonverbal Emotional Signals in Women With Borderline Personality Disorder: Evidence of a Negative Bias and an Increased Reliance on Nonverbal Cues

Studies conducted in patients diagnosed with borderline personality disorder (BPD) have documented a variety of anomalies concerning patients' abilities to interpret emotional signals. Attempting to clarify the bases of these anomalies, the current literature draws attention to a possible role of dysfunctional expectations, such as the expectation of social rejection. Dysfunctional expectations, however, may not only bias social interpretations, but may also focus attention on social cues most important in conveying emotional messages, such as nonverbal signals. To explore these assumptions, 30 female BPD patients were tasked to judge the valence of emotional states conveyed by combinations of verbal and nonverbal emotional cues. Compared to controls, BPD patients exhibited a negative bias in their interpretations and relied more on available nonverbal cues. Shifts in the relative importance of nonverbal cues appeared to be rooted mainly in a reduced reliance on positive verbal cues presumably deemed less credible by BPD patients.

Computer Scoring of Emotional Awareness in a Nonclinical Population of Young Adults

The Levels of Emotional Awareness Scale (LEAS; Lane, Quinlan, Schwartz, Walker, & Zeitlin, 1990 ) is an open-ended measure of the ability to describe emotional reactions. Scoring the LEAS by hand is complex and time consuming (Barchard, Bajgar, Leaf, & Lane, 2010 ). Therefore, Program for Open-Ended Scoring (POES; Leaf & Barchard, 2010 ) was designed to score the LEAS quickly and easily. Using 268 undergraduates, this article compares traditional LEAS hand scoring to 6 POES methods, 2 of which are holistic methods that have never before been examined. Based on split-half reliability, correlations with measures of emotional and social intelligence, and partial correlations once response length and vocabulary were partialed out, we recommend 3 of the POES methods when testing nonclinical samples of young adults. Because POES scoring is fast and efficient, it allows more researchers and clinicians to use the LEAS, thus moving away from self-report measures of emotional awareness.

Impulsivity and aggression mediate regional brain responses in Borderline Personality Disorder: An fMRI study

Fronto-limbic brain networks involved in regulation of impulsivity and aggression are abnormal in Borderline Personality Disorder (BPD). However, it is unclear whether, or to what extent, these personality traits actually modulate brain responses during cognitive processing. Using fMRI, we examined the effects of trait impulsivity, aggression, and depressed mood on regional brain responses in 31 female BPD and 25 control subjects during a Go No-Go task using Ekman faces as targets. First-level contrasts modeled effects of negative emotional context. Second-level regression models used trait impulsivity, aggression and depressed mood as predictor variables of regional brain activations. In BPD, trait impulsivity was positively correlated with activation in the dorsal anterior cingulate cortex, orbital frontal cortex (OFC), basal ganglia (BG), and dorsolateral prefrontal cortex, with no areas of negative correlation. In contrast, aggression was negatively correlated with activation in OFC, hippocampus, and BG, with no areas of positive correlation. Depressed mood had a generally dampening effect on activations. Effects of trait impulsivity on healthy controls differed from effects in BPD, suggesting a disorder-specific response. Negative emotional context and trait impulsivity, but not aggression or depression, diminished task performance across both groups. Negative emotional context may interfere with cognitive functioning in BPD through interaction with the neurobiology of personality traits.

Die Dialectical Behavior Therapy Ways of Coping Checklist (DBT-WCCL)

Zusammenfassung. Ziel dieser Arbeit war die Erprobung und Validierung einer deutschen Version der Dialectical Behavior Therapy Ways of Coping Checklist (DBT-WCCL, Neacsiu, Rizui, Vitaliano, Lynch & Linehan, 2010 ), einem Fragebogen zur Erhebung der Häufigkeit der Nutzung von Skills, wie sie im Rahmen der Dialektisch-Behavioralen Therapie (DBT) vermittelt werden. Hierzu bearbeiteten 150 Patientinnen mit Borderline Persönlichkeitsstörung eine deutschsprachige Übersetzung, sowie Fragebögen zur Symptomschwere. Weitere 40 Patientinnen füllten die DBT-WCCL im Rahmen einer stationären DBT zu 5 Messzeitpunkten aus. Die drei Faktoren der Originalversion ließen sich replizieren. Weiterführende Analysen zeigten gute interne Konsistenzen und Retest-Reliabilitäten. Erwartungsgemäße Zunahmen auf der Subskala zur Erfassung von Skillsanwendung während der stationären DBT sowie erwartungsgemäße Zusammenhänge der DBT-WCCL mit der Skills- und DBT-Erfahrung geben erste Hinweise auf die Validität des Verfahrens.

Emotional Processes in Borderline Personality Disorder: An Update for Clinical Practice

Despite prior assumptions about poor prognosis, the surge in research on borderline personality disorder (BPD) over the past several decades shows that it is treatable and can have a good prognosis. Prominent theories of BPD highlight the importance of emotional dysfunction as core to this disorder. However, recent empirical research suggests a more nuanced view of emotional dysfunction in BPD. This research is reviewed in the present article, with a view towards how these laboratory-based findings can influence clinical work with individuals suffering from BPD.

Differences in Facial Emotion Recognition between First Episode Psychosis, Borderline Personality Disorder and Healthy Controls

Background

Facial emotion recognition (FER) is essential to guide social functioning and behaviour for interpersonal communication. FER may be altered in severe mental illness such as in psychosis and in borderline personality disorder patients. However, it is unclear if these FER alterations are specifically related to psychosis. Awareness of FER alterations may be useful in clinical settings to improve treatment strategies. The aim of our study was to examine FER in patients with severe mental disorder and their relation with psychotic symptomatology.

Materials and Methods

Socio-demographic and clinical variables were collected. Alterations on emotion recognition were assessed in 3 groups: patients with first episode psychosis (FEP) (n = 64), borderline personality patients (BPD) (n = 37) and healthy controls (n = 137), using the Degraded Facial Affect Recognition Task. The Positive and Negative Syndrome Scale, Structured Interview for Schizotypy Revised and Community Assessment of Psychic Experiences scales were used to assess positive psychotic symptoms. WAIS III subtests were used to assess IQ.

Results

Kruskal-Wallis analysis showed a significant difference between groups on the FER of neutral faces score between FEP, BPD patients and controls and between FEP patients and controls in angry face recognition. No significant differences were found between groups in the fear or happy conditions. There was a significant difference between groups in the attribution of negative emotion to happy faces. BPD and FEP groups had a much higher tendency to recognize happy faces as negatives. There was no association with the different symptom domains in either group.

Conclusions

FEP and BPD patients have problems in recognizing neutral faces more frequently than controls. Moreover, patients tend to over-report negative emotions in recognition of happy faces. Although no relation between psychotic symptoms and FER alterations was found, these deficits could contribute to a patient’s misinterpretations in daily life.

Stress, Emotion, and Coping Strategies as Predictors of Personality Disorder Pathology

The utility of coping strategies, stress, and emotion as predictors of personality disorder pathology was examined by exposing subjects to a set of stressful scenarios. It was predicted that personality disorder (PD) would be associated with less adaptive coping strategies, higher stress, low control, and low perception of coping efficacy. In general, the results indicated strong correlations between PD and the coping strategies of escape-avoidance and accepting responsibility and weak or negative associations with the problem-solving and positive reappraisal strategies. Personality disorder was associated with stress, negative emotions, and low control/efficacy. The coping/emotion profiles are useful in elaborating and discriminating similarities and differences between PDs.

Dialectical behavior therapy skills use and emotion dysregulation in personality disorders and psychopathy: a community self-report study

BACKGROUND

Emotion dysregulation is a critical transdiagnostic mental health problem that needs to be further examined in personality disorders (PDs). The current study examined dialectical behavior therapy (DBT) skills use, emotion dysregulation, and dysfunctional coping among adults who endorsed symptoms of cluster B PDs and psychopathy. We hypothesized that skills taught in DBT and emotion dysregulation are useful for adults with PDs other than borderline personality disorder (BPD).

METHODS

Using a self-report questionnaire, we examined these constructs in three groups of community adults: those who reported symptoms consistent with borderline personality disorder (BPD; N = 29), those who reported symptoms consistent with any other cluster B PD (N = 22), and those with no reported cluster B PD symptoms (N = 77) as measured by the Personality Diagnostic Questionnaire-4 + .

RESULTS

Both PD groups reported higher emotion dysregulation and dysfunctional coping when compared to the no PD group. Only the BPD group had significantly lower DBT skills use. DBT skills use was found to be a significant predictor of cluster B psychopathology but only before accounting for emotion dysregulation. When added to the regression model, emotion dysregulation was found to be a significant predictor of cluster B psychopathology but DBT skills use no longer had a significant effect. Across all groups, DBT skills use deficits and maladaptive coping, but not emotion dysregulation, predicted different facets of psychopathy.

CONCLUSION

Emotion dysregulation and use of maladaptive coping are problems in cluster B PDs, outside of BPD, but not in psychopathy. Inability to use DBT skills may be unique to BPD. Because this study relied exclusively on self-report, this data is preliminary and warrants further investigation.

Sex Differences in Emotional Awareness

The present study examined sex differences in the complexity and differentiation of people’s representations of emotional experience. Female participants from seven different samples, ranging in age, scholastic performance, socioeconomic status, and culture, scored higher on a performance test of emotional awareness than did male participants. Women consistently displayed more complexity and dif ferentiation in their articulations of emotional experiences than did men, even when the effect of verbal intelligence was controlled. Together, the findings suggest that a sex difference in display of emotional awareness is a stable, highly generalizable effect. Implications of these findings are presented.

Deficits in Degraded Facial Affect Labeling in Schizophrenia and Borderline Personality Disorder

Although deficits in facial affect processing have been reported in schizophrenia as well as in borderline personality disorder (BPD), these disorders have not yet been directly compared on facial affect labeling. Using degraded stimuli portraying neutral, angry, fearful and angry facial expressions, we hypothesized more errors in labeling negative facial expressions in patients with schizophrenia compared to healthy controls. Patients with BPD were expected to have difficulty in labeling neutral expressions and to display a bias towards a negative attribution when wrongly labeling neutral faces. Patients with schizophrenia (N = 57) and patients with BPD (N = 30) were compared to patients with somatoform disorder (SoD, a psychiatric control group; N = 25) and healthy control participants (N = 41) on facial affect labeling accuracy and type of misattributions. Patients with schizophrenia showed deficits in labeling angry and fearful expressions compared to the healthy control group and patients with BPD showed deficits in labeling neutral expressions compared to the healthy control group. Schizophrenia and BPD patients did not differ significantly from each other when labeling any of the facial expressions. Compared to SoD patients, schizophrenia patients showed deficits on fearful expressions, but BPD did not significantly differ from SoD patients on any of the facial expressions. With respect to the type of misattributions, BPD patients mistook neutral expressions more often for fearful expressions compared to schizophrenia patients and healthy controls, and less often for happy compared to schizophrenia patients. These findings suggest that although schizophrenia and BPD patients demonstrate different as well as similar facial affect labeling deficits, BPD may be associated with a tendency to detect negative affect in neutral expressions.

A Cognitive-Developmental Model of Emotional Awareness and Its Application to the Practice of Psychotherapy

The ability to be aware of one's own emotional states has been a time-honored ingredient of successful psychodynamic psychotherapy. With the rise of cognitive-behavioral therapy (CBT), however, the utility of experiencing and reflecting upon emotional experience has become less certain, and a quantifiable measure of emotional awareness for clinicians has not been previously available. Several recent advances cast the role of emotional awareness in psychotherapy in a different light: (1) a new theory of change in psychotherapy has been formulated that highlights emotional experience as an important ingredient of change in a variety of modalities; (2) new evidence shows that individual differences in the capacity for emotional awareness predict successful psychotherapeutic outcome in the treatment of panic disorder both by manualized psychodynamic psychotherapy and CBT; and (3) a new online version of the electronic Levels of Emotional Awareness Scale (eLEAS) has been created that can be used with individual patients as a guide to psychotherapy treatment. Here we review evidence of a reliable and valid measure of emotional awareness that has been used in both normative and clinical contexts. The psychotherapeutic treatment of three patients is described to illustrate the clinical manifestations of the different levels of emotional awareness and the ways the eLEAS can be useful in the clinical context, including (1) assessment of the patient's current level of emotional functioning and his or her potential for higher levels of functioning, (2) the targeting of interventions to facilitate functioning at the next level, and (3) a possible marker of treatment progress. These observations suggest that the eLEAS has the potential to be a clinically useful tool that may assist clinicians in guiding psychotherapy treatment.

Characterizing Positive and Negative Emotional Experiences in Young Adults With Borderline Personality Disorder Symptoms

OBJECTIVES

Some researchers suggest that borderline personality disorder (BPD) is characterized by elevated negative emotion; others argue that BPD involves both reduced positive and increased negative emotion. This study characterizes the emotional experiences of individuals with BPD symptoms in a combined university and community sample.

METHOD

Participants (N = 150) completed a clinical interview assessing BPD symptoms and self-report measures of positive and negative emotion. A subset (n = 106) completed a measure of emotion daily for 2 weeks. Pearson's correlations and multilevel modeling were used to examine the cross-sectional and longitudinal relationships between BPD symptoms and emotions.

RESULTS

BPD symptoms were robustly related to increased negative emotion; this relationship remained after accounting for positive emotion. BPD symptoms were weakly related to decreased positive emotion; this relationship was no longer significant after accounting for negative emotion. BPD symptoms predicted higher levels of negative and not positive emotion over 14 days. These patterns held for subscales assessing intensity, frequency, and duration of negative and positive emotions.

CONCLUSION

Findings suggest that individuals with BPD features are chiefly distinguished by elevated negative emotional experience.

Time course of facial emotion processing in women with borderline personality disorder: an ERP study

BACKGROUND

Borderline personality disorder (BPD) is characterized by a negative perception of others. Previous studies have revealed deficits and biases in facial emotion recognition. This study investigates the behavioural and electrophysiological correlates underlying facial emotion processing in individuals with BPD.

METHODS

The present study was conducted between July 2012 and May 2014. In an emotion classification task, unmedicated female patients with BPD as well as healthy women had to classify faces displaying blends of anger and happiness while the electroencephalogram was recorded. We analyzed visual event-related potentials (ERPs) reflecting early (P100), structural (N170) and categorical (P300) facial processing in addition to behavioural responses.

RESULTS

We included 36 women with BPD and 29 controls in our analysis. Patients with BPD were more likely than controls to classify predominantly happy faces as angry. Independent of facial emotion, women with BPD showed enhanced early occipital P100 amplitudes. Additionally, temporo-occipital N170 amplitudes were reduced at right hemispherical electrode sites. Centroparietal P300 amplitudes were reduced particularly for predominantly happy faces and increased for highly angry faces in women with BPD, whereas in healthy volunteers this component was modulated by both angry and happy facial affect.

LIMITATIONS

Our sample included only women, and no clinical control group was investigated.

CONCLUSION

Our findings suggest reduced thresholds for facial anger and deficits in the discrimination of facial happiness in individuals with BPD. This biased perception is associated with alterations in very early visual as well as deficient structural and categorical processing of faces. The current data could help to explain the negative perception of others that may be related to the patients' impairments in interpersonal functioning.

Elevated Preattentive Affective Processing in Individuals with Borderline Personality Disorder: A Preliminary fMRI Study

BACKGROUND

Emotion dysregulation is central to the clinical conceptualization of borderline personality disorder (BPD), with individuals often displaying instability in mood and intense feelings of negative affect. Although existing data suggest important neural and behavioral differences in the emotion processing of individuals with BPD, studies thus far have only explored reactions to overt emotional information. Therefore, it is unclear if BPD-related emotional hypersensitivity extends to stimuli presented below the level of conscious awareness (preattentively).

METHODS

Functional magnetic resonance imaging (fMRI) was used to measure neural responses to happy, angry, fearful, and neutral faces presented preattentively, using a backward masked affect paradigm. Given their tendency toward emotional hyperreactivity and altered amygdala and frontal activation, we hypothesized that individuals with BPD would demonstrate a distinct pattern of fMRI responses relative to those without BPD during the viewing of masked affective versus neutral faces in specific regions of interests (ROIs).

RESULTS

RESULTS indicated that individuals with BPD demonstrated increases in frontal, cingulate, and amygdalar activation represented by number of voxels activated and demonstrated a different pattern of activity within the ROIs relative to those without BPD while viewing masked affective versus neutral faces.

CONCLUSION

These findings suggest that in addition to the previously documented heightened responses to overt displays of emotion, individuals with BPD also demonstrate differential responses to positive and negative emotions, early in the processing stream, even before conscious awareness.

Factors contributing to social cognition impairment in borderline personality disorder and schizophrenia

Social cognition (SC) deficits have been described both in patients with schizophrenia and borderline personality disorder (BPD). However, while the former tend towards simplistic mental state attributions (undermentalizing), the latter are more likely to make overly complex mental state inferences (overmentalizing). Performance on complex SC tasks has been shown to correlate with neurocognitive ability, emotion perception, a history of trauma, and overconfidence in errors. However, it is unclear how these factors relate to different aspects of SC deficits. Aim of the present study was to examine the pathways of SC impairment by investigating performance profiles and their predictors comparatively in BPD and schizophrenia. Participants were 44 patients with BPD, 36 patients with schizophrenia, and 38 healthy controls. Undermentalizing and overmentalizing were assessed with an ecologically valid SC task. Patients with BPD exhibited increased overmentalizing, whereas patients with schizophrenia showed a more extensive deficit pattern, their main error type being undermentalizing. Overconfidence in errors was the most important predictor for overmentalizing, while undermentalizing depended mainly on verbal memory and emotion perception. Thus, BPD und schizophrenia exhibited different SC impairment patterns, and different types of SC errors were predicted by different factors. These findings have implications for the optimization of treatment approaches.

Characterizing emotional dysfunction in borderline personality, major depression, and their co-occurrence

This research aimed to characterize patterns of emotional reactivity and dysregulation in borderline personality, depression, and their co-occurrence. In study 1, 488 young adult women from the community were categorized into four groups based on self-reported major depressive disorder (MDD) and borderline personality disorder (BPD) symptoms (Low BPD/Low MDD; Low BPD/High MDD; High BPD/Low MDD; High BPD/High MDD). Immediate and prolonged subjective emotional reactivity to a laboratory stressor were assessed, and participants completed self-report and behavioral measures of emotion dysregulation. Study 2 extended these findings, examining emotional reactivity and dysregulation in a clinical population of 176 substance dependent patients with diagnoses of BPD and MDD and including a biological index of emotional reactivity. Results revealed greater prolonged fear reactivity in the High BPD/High MDD (vs. Low BPD/Low MDD) group in study 1, and greater prolonged anxiety and negative affect reactivity in both High BPD groups (vs. Low BPD/Low MDD and Low BPD/High MDD groups) in study 2 (but no differences in cortisol reactivity). Results also demonstrated greater subjective (but not behavioral) emotion dysregulation in the High BPD/High MDD (vs. Low BPD/Low MDD) group in study 1 and both High BPD groups (vs. both Low BPD groups) in study 2. Finally, the High BPD/High MDD group reported greater difficulties controlling impulsive behaviors compared with all other groups in study 1 and the Low BPD groups in study 2. Findings suggest that BPD pathology (but not MDD pathology alone) is characterized by greater prolonged emotional (especially anxiety/fear-related) reactivity and heightened emotion dysregulation.

Emotional hyperreactivity in response to childhood abuse by primary caregivers in patients with borderline personality disorder

BACKGROUND

One of the core postulated features of borderline personality disorder (BPD) is extreme emotional reactivity to a wide array of evocative stimuli. Findings from previous experimental research however are mixed, and some theories suggest specificity of hyper emotional responses, as being related to abuse, rejection and abandonment only.

OBJECTIVE

The current experiment examines the specificity of emotional hyperreactivity in BPD.

METHOD

The impact of four film clips (BPD-specific: childhood abuse by primary caregivers; BPD-nonspecific: peer bullying; positive; and neutral) on self-reported emotional affect was assessed in three female groups; BPD-patients (n = 24), cluster C personality disorder patients (n = 17) and non-patient controls (n = 23).

RESULTS

Results showed that compared to the neutral film clip, BPD-patients reacted with more overall negative affect following the childhood abuse clip, and with more anger following the peer bullying clip than the two other groups.

LIMITATIONS

The current study was restricted to assessment of the impact of evocative stimuli on self-reported emotions, and the order in which the film clips were presented to the participants was fixed.

CONCLUSIONS

Results suggest that BPD-patients only react generally excessively emotional to stimuli related to childhood abuse by primary caregivers, and with excessive anger to peer-bullying stimuli. These findings are thus not in line with the core idea of general emotional hyperreactvity in BPD.

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.

Affective context interferes with brain responses during cognitive processing in borderline personality disorder: fMRI evidence

Emotion dysregulation in borderline personality disorder (BPD) is associated with loss of cognitive control in the face of intense negative emotion. Negative emotional context may interfere with cognitive processing through the dysmodulation of brain regions involved in regulation of emotion, impulse control, executive function and memory. Structural and metabolic brain abnormalities have been reported in these regions in BPD. Using novel fMRI protocols, we investigated the neural basis of negative affective interference with cognitive processing targeting these regions. Attention-driven Go No-Go and X-CPT (continuous performance test) protocols, using positive, negative and neutral Ekman faces, targeted the orbital frontal cortex (OFC) and the anterior cingulate cortex (ACC), respectively. A stimulus-driven Episodic Memory task, using images from the International Affective Pictures System, targeted the hippocampus (HIP). Participants comprised 23 women with BPD, who were compared with 15 healthy controls. When Negative>Positive faces were compared in the Go No-Go task, BPD subjects had hyper-activation relative to controls in areas reflecting task-relevant processing: the superior parietal/precuneus and the basal ganglia. Decreased activation was also noted in the OFC, and increased activation in the amygdala (AMY). In the X-CPT, BPD subjects again showed hyper-activation in task-relevant areas: the superior parietal/precuneus and the ACC. In the stimulus-driven Episodic Memory task, BPD subjects had decreased activation relative to controls in the HIP, ACC, superior parietal/precuneus, and dorsal prefrontal cortex (dPFC) (for encoding), and the ACC, dPFC, and HIP for retrieval of Negative>Positive pictures, reflecting impairment of task-relevant functions. Negative affective interference with cognitive processing in BPD differs from that in healthy controls and is associated with functional abnormalities in brain networks reported to have structural or metabolic abnormalities. Task demands exert a differential effect on the cognitive response to negative emotion in BPD compared with control subjects.

Childhood trauma, midbrain activation and psychotic symptoms in borderline personality disorder

Childhood trauma is believed to contribute to the development of borderline personality disorder (BPD), however the mechanism by which childhood trauma increases risk for specific symptoms of the disorder is not well understood. Here, we explore the relationship between childhood trauma, brain activation in response to emotional stimuli and psychotic symptoms in BPD. Twenty individuals with a diagnosis of BPD and 16 healthy controls were recruited to undergo a functional MRI scan, during which they viewed images of faces expressing the emotion of fear. Participants also completed the childhood trauma questionnaire (CTQ) and a structured clinical interview. Between-group differences in brain activation to fearful faces were limited to decreased activation in the BPD group in the right cuneus. However, within the BPD group, there was a significant positive correlation between physical abuse scores on the CTQ and BOLD signal in the midbrain, pulvinar and medial frontal gyrus to fearful (versus neutral) faces. In addition there was a significant correlation between midbrain activation and reported psychotic symptoms in the BPD group (P<0.05). These results show that physical abuse in childhood is, in individuals with BPD, associated with significantly increased activation of a network of brain regions including the midbrain in response to emotional stimuli. Sustained differences in the response of the midbrain to emotional stimuli in individuals with BPD who suffered childhood physical abuse may underlie the vulnerability of these patients to developing psychotic symptoms.

Social perception in borderline personality disorder: the role of context

The purpose of this study was to examine social and nonsocial context processing in persons with borderline personality disorder (BPD). A secondary goal was to examine social perception in this population. The performance of 23 individuals with DSM-IV-diagnosed BPD was compared to a nonclinical control sample of 40 individuals. The participants were asked to perform both a social perceptual task that requires social context processing and a nonsocial context processing task. Social perception was examined using the Profile of Nonverbal Sensitivity (PONS). The results demonstrate that the group with BPD was impaired on all tasks relative to the control group. Yet their reaction time improved when provided with social context. Implications for future research are discussed.

Hostility, flooding, and relationship satisfaction: Predicting trajectories of psychological aggression across the transition to parenthood

Psychological aggression has been shown to have harmful effects on both partners, sometimes above and beyond the effects of physical aggression. However, very little is known about psychological aggression during the transition to parenthood. The transition to parenthood is a time where relationship satisfaction often declines and stress increases, which may put the couples at higher risk for psychological aggression. The purpose of this study was to examine if prenatal risk factors related to interpersonal style (specifically, emotional flooding and hostility) predict changes in psychological aggression from pregnancy to 2 years postpartum. Ninety eight couples took part in this study. The couples completed self-report questionnaires during pregnancy, 1 year postpartum, and 2 years postpartum. Both partners were asked about perpetrating and experiencing psychological aggression in their current relationship. Two level Hierarchical Linear Models (HLMs) were used to examine longitudinal associations between hostility, flooding, and psychological aggression. For women, hostility during pregnancy was a significant longitudinal predictor of psychological aggression. For men, flooding was a significant longitudinal predictor of psychological aggression. For both men and women, relationship satisfaction partially mediated the relationship between flooding/hostility and psychological aggression, indicating that women's hostile attitudes and men's tendency to be flooded tend to erode relationship quality, leading to increases in psychological aggression. This may represent a classic demand-withdraw dynamic in couples. The results indicate hostility for women and flooding for men are potential prenatal risk factors for future psychological aggression. Implications and future research directions are discussed. Aggr. Behav. 42:134-148, 2015. © 2014 Wiley Periodicals, Inc.

The influence of stress on social cognition in patients with borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is characterized by severe difficulties in interpersonal relationships and emotional functioning. Theories of BPD suggest that individuals with BPD have heightened emotional sensitivity, increased stress reactivity, and problems in making sense of intentions of others. In this study we investigated stress reactivity in BPD and its interference with social cognition, and tested whether any differences are specific for BPD or are inherent to personality disorders in general.

METHODS

We investigated 22 patients with BPD, 23 patients with Cluster C personality disorder (CPD), and 24 nonpatients on facial emotion recognition and social evaluation before and after stress induction based on the Trier Social Stress Test (TSST).

RESULTS

The results show that stress increased subjective negative emotions in the BPD group to a larger extent than in the other groups, whereas physiological responses were attenuated. Importantly stress induction increased negative evaluations about others, but surprisingly to a similar extent in the BPD and CPD groups as in the nonpatient control group. In addition facial emotion recognition performance was higher after than before stress, but no significant group differences were observed.

CONCLUSION

These results suggest that heightened psychological reactivity in BPD co-occurs with attenuated physiological responses to psychosocial stress and that stress affects social cognition to a similar extent in BPD as in others.

Emotion recognition in borderline personality disorder: effects of emotional information on negative bias

BACKGROUND

Borderline Personality Disorder (BPD) is characterized by severe deficits in social interactions, which might be linked to deficits in emotion recognition. Research on emotion recognition abilities in BPD revealed heterogeneous results, ranging from deficits to heightened sensitivity. The most stable findings point to an impairment in the evaluation of neutral facial expressions as neutral, as well as to a negative bias in emotion recognition; that is the tendency to attribute negative emotions to neutral expressions, or in a broader sense to report a more negative emotion category than depicted. However, it remains unclear which contextual factors influence the occurrence of this negative bias. Previous studies suggest that priming by preceding emotional information and also constrained processing time might augment the emotion recognition deficit in BPD.

METHODS

To test these assumptions, 32 female BPD patients and 31 healthy females, matched for age and education, participated in an emotion recognition study, in which every facial expression was preceded by either a positive, neutral or negative scene. Furthermore, time constraints for processing were varied by presenting the facial expressions with short (100 ms) or long duration (up to 3000 ms) in two separate blocks.

RESULTS

BPD patients showed a significant deficit in emotion recognition for neutral and positive facial expression, associated with a significant negative bias. In BPD patients, this emotion recognition deficit was differentially affected by preceding emotional information and time constraints, with a greater influence of emotional information during long face presentations and a greater influence of neutral information during short face presentations.

CONCLUSIONS

Our results are in line with previous findings supporting the existence of a negative bias in emotion recognition in BPD patients, and provide further insights into biased social perceptions in BPD patients.

Identity disturbance and problems with emotion regulation are related constructs across diagnoses

OBJECTIVE

This study examined the relation between identity disturbance and emotion dysregulation in a cross-diagnostic sample. We assessed whether these constructs are related and relevant beyond borderline personality disorder (BPD).

METHOD

We recruited 127 participants who completed measures assessing identity disturbance, emotion dysregulation, anxiety, and depression. The sample included primarily depressed adults meeting criteria for multiple diagnoses as well as psychiatrically healthy participants.

RESULTS

Identity disturbance was significantly higher among psychiatric participants with and without BPD compared to healthy controls. Emotion dysregulation was a significant predictor of identity disturbance, even when controlling for BPD diagnosis, depression, and anxiety. In particular, clarity in emotional situations and problems using emotion regulation strategies were most closely related to identity disturbance.

CONCLUSION

The results of this study suggest that future research should examine identity disturbance and its relation with emotion regulation transdiagnostically.

Metacognitive dysfunctions in personality disorders: correlations with disorder severity and personality styles

Metacognitive impairment is crucial to explaining difficulties in life tasks of patients with personality disorders (PDs). However, several issues remain open. There is a lack of evidence that metacognitive impairments are more severe in patients with PDs. The relationship between severity of PD pathology and the extent of metacognitive impairment has not been explored, and there has not been any finding to support the linking of different PDs with specific metacognitive profiles. The authors administered the Metacognitive Assessment Interview to 198 outpatients with PDs and 108 outpatients with no PDs, differentiating overall severity from stylistic elements of personality pathology. Results showed that metacognitive impairments were more severe in the group with PDs than in the control group, and that metacognitive dysfunctions and the severity of the PD were highly associated. Positive correlations were found between specific metacognitive dysfunctions and specific personality styles. Results suggest that metacognitive impairments could be considered a common pathogenic factor for PDs.

[Expression, identification and experience of emotions in mental diseases. An overview]

Several studies in clinical neuroscience have focused on the analysis of expression of emotions, identification of emotions and experience of emotions. These empirical studies produced certain insights into emotional competency in different mental diseases, most of them in schizophrenia. The current article gives a description of the scientific data about alterations in emotional competency in several mental diseases (e.g. schizophrenia, depression, bipolar and borderline diseases) and links the data, if possible, with clinical relevance with a special focus on emotional competency in prodromal schizophrenia.