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

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

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

Impact of social exclusion on empathy in women with borderline personality disorder

Unstable interpersonal relationships and fear of abandonment are core symptoms of borderline personality disorder (BPD) that often intensify during stress. Psychosocial stress, which includes components of social exclusion and increases cortisol secretion, enhances emotional empathy in healthy individuals. Women with BPD, on the contrary, react with reduced emotional empathy. The aim of the present study was to investigate the effects of perceived social exclusion without accompanying cortisol increase on empathy in women with BPD and healthy women. To induce social exclusion, we randomized 98 women with BPD and 98 healthy women to either an exclusion or an overinclusion (control) condition of Cyberball, a virtual ball game. Subsequently, participants underwent the Multifaceted Empathy Test (MET), which assesses cognitive and emotional empathy. There was no increase in cortisol release after Cyberball. Cognitive empathy did not differ between groups or conditions. Women with BPD reported lower emotional empathy for positive emotions (group by valence interaction), but not for negative emotions. Exploratory analyses suggested that this effect might be more pronounced after social exclusion. Our results confirm previous findings that cognitive empathy does not differ between women with BPD and healthy women and extend this evidence to social exclusion. Emotional empathy in women with BPD seems to be more sensitive to the effects of stress or ambiguous social situations. Specifically, emotional empathy seems to be reduced for positive emotions, and might further decline after social exclusion. Empathic reactions to emotional stimuli of different valences and to specific emotions should be further investigated.

Bared-teeth displays in bonobos (Pan paniscus): An assessment of the power asymmetry hypothesis

Facial expressions are key to navigating social group life. The Power Asymmetry Hypothesis of Motivational Emancipation predicts that the type of social organization shapes the meaning of communicative displays in relation to an individual's dominance rank. The bared-teeth (BT) display represents one of the most widely observed communicative signals across primate species. Studies in macaques indicate that the BT display in despotic species is often performed unidirectionally, from low- to high-ranking individuals (signaling submission), whereas the BT display in egalitarian species is usually produced irrespective of dominance (mainly signaling affiliation and appeasement). Despite its widespread presence, research connecting BT displays to the power asymmetry hypothesis outside the Macaca genus remains scarce. To extend this knowledge, we investigated the production of BT in relation to social dominance in dyadic interactions (N = 11,377 events) of 11 captive bonobos (Pan paniscus). Although adult bonobos were more despotic than previously suggested in the literature, BT displays were produced irrespective of dominance rank. Moreover, while adults produced the BT exclusively during socio-sexual interactions, especially during periods of social tension, immature bonobos produced the BT in a wider number of contexts. As such, the results indicate that the communicative meaning of the BT display is consistent with signaling appeasement, especially in periods of social tension. Moreover, the BT display does not seem to signal social status, supporting the prediction for species with a high degree of social tolerance. These results advance our understanding of the origins of communicative signals and their relation to species' social systems.

The Influence of Attachment Style, Self-protective Beliefs, and Feelings of Rejection on the Decline and Growth of Trust as a Function of Borderline Personality Disorder Trait Count

Borderline personality disorder (BPD) is associated with paradoxical trust behaviours, specifically a faster rate of trust growth in the face of trust violations. The current study set out to understand whether attachment style, self-protective beliefs, and feelings of rejection underpin this pattern. Young adults (N=234) played a 15-round trust game in which partner cooperation was varied to create three phases of trust: formation, dissolution, and restoration. Discontinuous growth modelling was employed to observe whether the effect of BPD trait count on trust levels and growth is moderated by fearful or preoccupied attachment style, self-protective beliefs, and feelings of rejection. Results suggest that the slower rate of trust formation associated with BPD trait count was accounted for by feelings of rejection or self-protective beliefs, both of which predicted a slower rate of trust growth. The faster rate of trust growth in response to trust violations associated with BPD trait count was no longer significant after self-protective beliefs were accounted for. Interventions targeting self-protective beliefs and feelings of rejection may address the trust-based interpersonal difficulties associated with BPD.

Computerized analysis of facial expressions in serious mental illness

Blunted facial affect is a transdiagnostic component of Serious Mental Illness (SMI) and is associated with a host of negative outcomes. However, blunted facial affect is a poorly understood phenomenon, with no known cures or treatments. A critical step in better understanding its phenotypic expression involves clarifying which facial expressions are altered in specific ways and under what contexts. The current literature suggests that individuals with SMI show decreased positive facial expressions, but typical, or even increased negative facial expressions during laboratory tasks. While this literature has coalesced around general trends, significantly more nuance is available regarding what components facial expressions are atypical and how those components are associated with increased severity of clinical ratings. The present project leveraged computerized facial analysis to test whether clinician-rated blunted affect is driven by decreases in duration, intensity, or frequency of positive versus other facial expressions during a structured clinical interview. Stable outpatients meeting criteria for SMI (N = 59) were examined. Facial expression did not generally vary as a function of clinical diagnosis. Overall, clinically-rated blunted affect was not associated with positive expressions, but was associated with decreased surprise and increased anger, sadness, and fear expressions. Blunted affect is not a monolithic lack of expressivity, and increased precision in operationally defining it is critical for uncovering its causes and maintaining factors. Our discussion focuses on this effort, and on advancing digital phenotyping of blunted facial affect more generally.

Sequential Social Exclusion in a Novel Cyberball Paradigm Leads to Reduced Behavioral Repair and Plasma Oxytocin in Borderline Personality Disorder

Patients with borderline personality disorder (BPD) show interpersonal deficits, and altered emotional and oxytocin (OT) responses to social exclusion (Cyberball). In order to extend previous findings, this study applies a novel Cyberball variant. Nineteen BPD patients and 56 healthy controls (HC) played Cyberball for 2 minutes of inclusion, 5 minutes of partial exclusion by one of two co-players, and 2 minutes total exclusion by both. Plasma OT levels at baseline and after 7, 9, 15, and 40 minutes were measured with radioimmunoassay. BPD patients showed a greater aversive reaction and a trend for greater OT reduction after social exclusion than HC. BPD patients also tended to play less frequently with the excluder. Though limited by our sample size, we partially replicate previous findings. Our preliminary behavioral data support the notion of an altered OT regulation and reduced capacity for social cooperation in BPD.

Autonomic vulnerability to biased perception of social inclusion in borderline personality disorder

BACKGROUND

Individuals with Borderline Personality Disorder (BPD) feel rejected even when socially included. The pathophysiological mechanisms of this rejection bias are still unknown. Using the Cyberball paradigm, we investigated whether patients with BPD, display altered physiological responses to social inclusion and ostracism, as assessed by changes in Respiratory Sinus Arrhythmia (RSA).

METHODS

The sample comprised 30 patients with BPD, 30 with remitted Major Depressive Disorder (rMDD) and 30 Healthy Controls (HC). Self-report ratings of threats toward one's fundamental need to belong and RSA reactivity were measured immediately after each Cyberball condition.

RESULTS

Participants with BPD showed lower RSA at rest than HC. Only patients with BPD, reported higher threats to fundamental needs and exhibited a further decline in RSA after the Inclusion condition.

CONCLUSIONS

Individuals with BPD experience a biased appraisal of social inclusion both at the subjective and physiological level, showing higher feelings of ostracism and a breakdown of autonomic regulation to including social scenarios.

Borderline Personality Disorder: Risk Factors and Early Detection

Personality disorders (PDs) exert a great toll on health resources, and this is especially true for borderline personality disorder (BPD). As all PDs, BPD arises during adolescence or young adulthood. It is therefore important to detect the presence of this PD in its earlier stages in order to initiate appropriate treatment, thus ameliorating the prognosis of this condition. This review aims to highlight the issues associated with BPD diagnosis in order to promote its early detection and treatment. To do so, we conducted a search on PubMed database of current evidence regarding BPD early diagnosis, focusing on risk factors, which represent important conditions to assess during young patient evaluation, and on diagnostic tools that can help the clinician in the assessment process. Our findings show how several risk factors, both environmental and genetic/neurobiological, can contribute to the onset of BPD and help identify at-risk patients who need careful monitoring. They also highlight the importance of a careful clinical evaluation aided by psychometric tests. Overall, the evidence gathered confirms the complexity of BDP early detection and its crucial importance for the outcome of this condition.

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

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

Dynamics of the immediate behavioral response to partial social exclusion

Social rejection and exclusion (ostracism) represent main stressors in daily life and even threaten mental and physical health. Abundant data from subjective measures in social exclusion paradigms are available, but the dynamic behavioral response is largely unexplored. Here, we applied modified variants of the Cyberball paradigm in two consecutive experiments to investigate the adaptive behavioral and emotional reactions to partial social exclusion. In experiment 1, 68 healthy participants (females, mean age 24.76 ± 4.05 years) played 2 min inclusion, 5 min partial exclusion and 2 min total exclusion. In experiment 2, 94 healthy participants (48 females, mean age 34.50 ± 12.08 years) underwent an experimental condition (2 min inclusion, 10 min partial exclusion) and a control condition (12 min inclusion only) in randomized order. In experiment 1, behavioral responses to partial exclusion showed two characteristics: (1) an immediate increase in ball passes to the excluding player followed (2) by a later return of participants’ behavior to baseline. This finding was replicated for both genders and in comparison to a control condition in experiment 2. The dynamic behavioral response observed here may point to overlapping principles of cooperation in this ball tossing paradigm and serves as a novel experimental proxy.

The Role of Trauma in Early Onset Borderline Personality Disorder: A Biopsychosocial Perspective

The role of childhood trauma in the development of borderline personality disorder (BPD) in young age has long been studied. The most accurate theoretical models are multifactorial, taking into account a range of factors, including early trauma, to explain evolutionary pathways of BPD. We reviewed studies published on PubMed in the last 20 years to evaluate whether different types of childhood trauma, like sexual and physical abuse and neglect, increase the risk and shape the clinical picture of BPD. BPD as a sequela of childhood traumas often occurs with multiple comorbidities (e.g. mood, anxiety, obsessive-compulsive, eating, dissociative, addictive, psychotic, and somatoform disorders). In such cases it tends to have a prolonged course, to be severe, and treatment-refractory. In comparison with subjects who suffer from other personality disorders, patients with BPD experience childhood abuse more frequently. Adverse childhood experiences affect different biological systems (HPA axis, neurotransmission mechanisms, endogenous opioid systems, gray matter volume, white matter connectivity), with changes persisting into adulthood. A growing body of evidence is emerging about interaction between genes (e.g. FKBP5 polymorphisms and CRHR2 variants) and environment (physical and sexual abuse, emotional neglect).

Electromyographic evidence of reduced emotion mimicry in individuals with a history of non-suicidal self-injury

Engaging in facial emotion mimicry during social interactions encourages empathy and functions as a catalyst for interpersonal bonding. Decreased reflexive mirroring of facial expressions has been observed in individuals with different non-psychotic disorders, relative to healthy controls. Given reports of interpersonal relationship difficulties experienced by those who engage in non-suicidal self-injury (NSSI), it is of interest to explore facial emotion mimicry in individuals with a history of this behaviour (HNSSI). Among other things, this will enable us to better understand their emotion regulation and social interaction challenges. Surface facial electromyography (fEMG) was used to record the reflexive facial mimicry of 30 HNSSI and 30 controls while they passively observed a series of dynamic facial stimuli showing various facial expressions of emotion. Beginning with a neutral expression, the stimuli quickly morphed to one of 6 prototypic emotional expressions (anger, fear, surprise, disgust, happiness, or sadness). Mimicry was assessed by affixing surface electrodes to facial muscles known to exhibit a high degree of electrical activity in response to positive and negative emotions: the corrugator supercilii and the zygomaticus major. HNSSI participants, relative to controls, exhibited significantly less electrical activity in the corrugator muscle in response to viewing angry stimuli, and significantly less of an expected relaxation in muscle activity in response to viewing happy stimuli. Mirroring these results, greater endorsement of social influence as a motivator for engaging in NSSI was associated with less mimicry, and greater endorsement of emotion regulation as a motivator was associated with greater incongruent muscle response when viewing happy faces. These findings lend support to the theory that social interaction difficulties in HNSSI might be related to implicit violations of expected social rules exhibited through facial mimicry nonconformity.

Negative bias and reduced visual information processing of socio-emotional context in borderline Personality Disorder: A support for the hypersensitivity hypothesis

BACKGROUND AND OBJECTIVES

Current studies on emotional dysregulation in BPD suggest that it might be manifested by altered appraisal and biased attentional mechanisms, rather than by hyperreactivity. The aim of this study was to acquire more evidence on this topic by testing the hypothesis that BPD patients are characterized by a negative evaluation bias and reduced visual exploration in response to socio-emotional content. Moreover, the association between the previous conceptualizations and typical dysfunctional processes in BPD were evaluated.

METHODS

Fifty-four socio-emotional pictures were administered to 20 female BPD patients and 20 healthy controls (HCs) divided into three blocks characterized by different stimulus durations (500 ms, 3s, 18s). Self-reported and eye-tracking data were collected during the experiment.

RESULTS

BPD patients showed lower valence ratings and reduced visual exploration of socio-emotional pictures compared to HCs. Visual exploration in BPD was affected by exposure time with reduced exploration in response to prolonged stimuli presentation. Dysfunctional features and pre-task negative affectivity level in BPD were correlated with self-reported evaluations and eye-tracking data.

LIMITATIONS

Possible effects of gender on emotional responsivity could not be addressed given the female composition of our sample. Moreover, the role of psychiatric symptoms and medications should be addressed in future research.

CONCLUSIONS

This study presented evidence on dysfunctional mechanisms sustaining emotional dysregulation in BPD. This construct seemed supported by a well-established negative bias towards emotional stimuli together with a reduced processing of social information as manifestations of emotional hypersensitivity.

Approach and Avoidance Behavior in Female Patients With Borderline Personality Disorder

Objectives

Borderline personality disorder (BPD) is portrayed by unstable relationships, fears of abandonment and heightened sensitivity to social rejection. Research has shown that these characteristics may lead to inappropriate social behavior including altered approach-avoidance behavior. However, it has remained unclear how social exclusion may affect approach-avoidance behavior in patients with BPD.

Design

We assessed social approach-avoidance behavior and the impact of social exclusion in a sample of 38 patients with BPD and 40 healthy control participants.

Methods

We used an explicit joystick-based approach-avoidance task (AAT) after playing a virtual ball-tossing game (Cyberball), which simulates the exclusion of the participant by two other players. In the AAT, participants were required to push or pull emotional stimuli, more specifically happy and angry facial expressions, with either direct or averted gaze direction.

Results

Patients with BPD approached happy stimuli less and showed overall less differential approach-avoidance behavior toward individuals expressing positive or negative facial emotions compared to healthy participants, who showed more approach behavior for happy compared to angry facial expressions. Moreover, borderline symptom severity correlated inversely with the AAT score for happy facial expressions and positively with subjective unpleasantness during social exclusion as well as rejection sensitivity. However, social exclusion did not influence approach-avoidance tendencies.

Conclusion

Patients with BPD showed altered approach-avoidance behavior, which might affect social interactions in the patient’s everyday lives and may therefore impede social interaction.

Brain responses to social feedback in internalizing disorders: A comprehensive review

Problems with interpersonal relationships are often a chief complaint among those seeking psychiatric treatment; yet heterogeneity and homogeneity across disorders suggests both common and unique mechanisms of impaired interpersonal relationships. Basic science research has begun yielding insights into how the brain responds to social feedback. Understanding how these processes differ as a function of psychopathology can begin to inform the mechanisms that give rise to such interpersonal dysfunction, potentially helping to identify differential treatment targets. We reviewed 46 studies that measured the relationship between brain responses to social feedback and internalizing psychopathology. We found that socially relevant anxiety was associated with amygdala hyperactivity to the anticipation of social feedback. Depression was related to hyperreactivity of regions in the cingulo-opercular network to negative social feedback. Borderline personality disorder (BPD) was associated with hyperactivity of regions in the default mode network to negative social feedback. The review also identified key insights into methodological limitations and potential future directions for the field.

Negative affect moderates the effect of social rejection on frontal and anterior cingulate cortex activation in borderline personality disorder

Patients with borderline personality disorder (BPD) have a heightened sensitivity to social exclusion. Experimental manipulations have produced inconsistent findings and suggested that baseline negative affect (NA) might influence the experience of exclusion. We administered a standardized social exclusion protocol (Cyberball paradigm) in BPD (n = 39) and age-matched and sex-matched healthy controls (n = 29) to investigate the association of NA on social exclusion and activation in brain regions previously implicated in this paradigm. Compared with controls, patients with BPD showed higher activation during social exclusion in the anterior cingulate cortex (ACC), the medial prefrontal cortex (mPFC), and in the right precuneus. Prescan NA ratings were associated with higher brain activation in the ACC and mPFC over all conditions, and post hoc t tests revealed that differences between the groups were only significant when controlling for NA. Brain activation during exclusion was correlated with NA separately for each group. Only BPD patients showed a significant association of NA and exclusion related precuneus activation (r = .52 p = .001). Additionally, BPD patients experienced less feelings of belonging compared with a healthy control (HC) group during inclusion and exclusion, although they estimated their ball possessions significantly higher than did the HC. These findings suggest that baseline NA has a crucial impact on Cyberball-related brain activation. The results underscore the importance of considering levels of NA in social exclusion protocols for participants high in this trait.

The vicious circle of social exclusion and psychopathology: a systematic review of experimental ostracism research in psychiatric disorders

Social exclusion (ostracism) is a major psychosocial factor contributing to the development and persistence of psychiatric disorders and is also related to their social stigma. However, its specific role in different disorders is not evident, and comprehensive social psychology research on ostracism has rather focused on healthy individuals and less on psychiatric patients. Here, we systematically review experimental studies investigating psychological and physiological reactions to ostracism in different responses of psychiatric disorders. Moreover, we propose a theoretical model of the interplay between psychiatric symptoms and ostracism. A systematic MEDLINE and PsycINFO search was conducted including 52 relevant studies in various disorders (some of which evaluated more than one disorder): borderline personality disorder (21 studies); major depressive disorder (11 studies); anxiety (7 studies); autism spectrum disorder (6 studies); schizophrenia (6 studies); substance use disorders (4 studies); and eating disorders (2 studies). Psychological and physiological effects of ostracism were assessed with various experimental paradigms: e.g., virtual real-time interactions (Cyberball), social feedback and imagined scenarios. We critically review the main results of these studies and propose the overall concept of a vicious cycle where psychiatric symptoms increase the chance of being ostracized, and ostracism consolidates or even aggravates psychopathology. However, the specificity and stability of reactions to ostracism, their neurobiological underpinnings, determinants, and moderators (e.g., attachment style, childhood trauma, and rejection sensitivity) remain elusive.

The Emotional Bank Account and the Four Horsemen of the Apocalypse in Romantic Relationships of People with Borderline Personality Disorder: A Dyadic Observational Study

Few studies have examined behaviors in romantic relationships associated with borderline personality disorder (BPD). We assessed critical variables from marital research: the "emotional bank account" (positive-to-negative behaviors; Gottman, 1993) and the "four horsemen of the apocalypse" (criticism, defensiveness, contempt, and stonewalling; Gottman & Silver, 1999; Gottman & Krokoff, 1989). Couples (N = 130, or 260 participants) engaged in a conflict task and reported relationship satisfaction at intake and 12-months. Clinician-rated BPD and avoidant PD (APD) criteria were examined. People with more BPD symptoms and their partners were less satisfied, which worsened by follow-up. Conflict behaviors partially explained these associations. Partners of people with more BPD symptoms had a worse emotional bank account, which then predicted (a) poorer satisfaction for both members and (b) worsening partner satisfaction. People with more BPD symptoms criticized more; their partners defended and stonewalled more. APD predicted worsening satisfaction. BPD appears to link specifically with relationship dysfunction, partly through associations with partner behavior.

Consider others better than yourself: Social decision-making and partner preference in Borderline Personality Disorder

BACKGROUND AND OBJECTIVES

Patients with Borderline Personality Disorder (BPD) suffer from interpersonal difficulties. They have been shown to be distrustful and yet involved in abusive relationships. In this study, we want to examine whether the perception of fairness and partner preference are altered in BPD.

METHODS

We employed a coalition formation game in which a participant can choose whether to interact in dyads or triads, thus exclusion or inclusion of a third potential interaction partner. Furthermore, triads get a higher endowment, such that dyads are not only unfair to one partner, but also economically inefficient, as the participant reduces the overall amount of money available for distribution. Subsequently, we compared how participants predicted another person's game strategy (inclusive, exclusive, or mixed) and rated its fairness, and which partner the participant would select.

RESULTS

The majority of the BPD group (n = 26) as well as of the healthy group (n = 29) preferred triads over dyads and offered a near-to-equal split to their interaction partners in the first two rounds. In contrast to the healthy group, the BPD group did not show a drop of the average level of investment in the final round. In both groups, the inclusive strategy was perceived as the fairest strategy. Most interestingly, despite a similar perception of fairness, half of the BPD group preferred an interaction partner with an exclusive or mixed strategy while the majority of the HC group would choose an interaction partner with an inclusive strategy.

LIMITATIONS

This is a preliminary study which needs further replications before strong conclusions can be drawn.

CONCLUSIONS

Our study demonstrates no differences in fairness perception but an alteration in partner preference of patients with BPD which might contribute to unfavorable partner choices and impairments of interpersonal functioning in BPD.

Pathoetiology and pathophysiology of borderline personality: Role of prenatal factors, gut microbiome, mu- and kappa-opioid receptors in amygdala-PFC interactions

The pathoetiology and pathophysiology of borderline personality disorder (BPD) have been relatively under-explored. Consequently, no targetted pharmaceutical treatments or preventative interventions are available. The current article reviews the available data on the biological underpinnings of BPD, highlighting a role for early developmental processes, including prenatal stress and maternal dysbiosis, in BPD pathoetiology. Such factors are proposed to drive alterations in the infant's gut microbiome, in turn modulating amygdala development and the amygdala's two-way interactions with other brain regions. Alterations in opioidergic activity, including variations in the ratio of the mu-and kappa-opioid receptors seem a significant aspect of BPD pathophysiology, contributing to its comorbidities with depression, anxiety, impulsivity and addiction. Stress and dysphoria are commonly experienced in people classed with BPD. A growing body of data, across a host of medical conditions, indicate that stress and mood dysregulation may be intimately associated with gut dysbiosis and increased gut permeability, coupled to heightened levels of oxidative stress and immune-inflammatory activity. It urgently requires investigation as to the relevance of such gut changes in the course of BPD symptomatology. Accumulating data indicates that BPD symptom exacerbations may be linked to cyclical variations in estrogen, in turn decreasing serotonin and local melatonin synthesis, and thereby overlapping with the pathophysiology of migraine and endometriosis, which also have a heightened association with BPD. Future research directions and treatment implications are indicated.

Stuck in a negative me: fMRI study on the role of disturbed self-views in social feedback processing in borderline personality disorder

BACKGROUND

Interpersonal difficulties in borderline personality disorder (BPD) could be related to the disturbed self-views of BPD patients. This study investigates affective and neural responses to positive and negative social feedback (SF) of BPD patients compared with healthy (HC) and low self-esteem (LSE) controls and how this relates to individual self-views.

METHODS

BPD (N = 26), HC (N = 32), and LSE (N = 22) performed a SF task in a magnetic resonance imaging scanner. Participants received 15 negative, intermediate and positive evaluative feedback words putatively given by another participant and rated their mood and applicability of the words to the self.

RESULTS

BPD had more negative self-views than HC and felt worse after negative feedback. Applicability of feedback was a less strong determinant of mood in BPD than HC. Increased precuneus activation was observed in HC to negative compared with positive feedback, whereas in BPD, this was similarly low for both valences. HC showed increased temporoparietal junction (TPJ) activation to positive v. negative feedback, while BPD showed more TPJ activation to negative feedback. The LSE group showed a different pattern of results suggesting that LSE cannot explain these findings in BPD.

CONCLUSIONS

The negative self-views that BPD have, may obstruct critically examining negative feedback, resulting in lower mood. Moreover, where HC focus on the positive feedback (based on TPJ activation), BPD seem to focus more on negative feedback, potentially maintaining negative self-views. Better balanced self-views may make BPD better equipped to deal with potential negative feedback and more open to positive interactions.

Response to ostracism in patients with chronic depression, episodic depression and borderline personality disorder a study using Cyberball

BACKGROUND

Social exclusion (ostracism) can lead to interactional frustration and may play an important role as trigger and symptom amplifier in affective disorders. To investigate immediate emotional and behavioral reactions as well as coping, social exclusion can be mimicked in experimental situations, e.g. in the Cyberball paradigm, a virtual ball tossing game which is well established in social psychology. The present cross-diagnostic study compares the responses to social exclusion in patients with chronic depression (CD), episodic depression (ED) and borderline personality disorder (BPD) in comparison to a healthy control group.

METHODS

After baseline characterization, 120 participants (29 patients with CD, 20 with ED, 28 with BPD and 43 healthy controls) played Cyberball with two virtual players and complete exclusion after three times receiving the ball. Thereafter, standard questionnaires were applied for measuring needs, threats, inner tension, emotions and behavioral intentions.

RESULTS

Patients with CD showed a higher intensity of ostracism and aversive impact, as well as the wish to escape the situation (behavioral intention) compared to ED. In most categories, CD and ED had scores between BPD and healthy controls (with this sequence) and with BPD patients showing the largest difference to healthy controls.

LIMITATIONS

The assessment did neither include objective behavioral measures (which is a general limitation in the majority of studies using Cyberball) nor any biological variables. The sample sizes of the diagnostic subgroups were moderate.

CONCLUSIONS

These findings support the hypothesis that social exclusion situations lead to a more aversive emotional and behavioral reaction in CD compared to ED. Psychological and biological underpinnings of these reactions should be addressed in future transdiagnostic studies. Moreover, psychotherapy in CD should focus on specific needs of CD patients for developing a functional coping in threatening interpersonal situations.

Facing exclusion and smiling through the pain: positive emotion expression during interpersonal ostracism

Background: The present research compares smiling and emotion expression generally to other indicators of negative intra- and interpersonal reactions to ostracism, and in particular negative reactions towards the ostracizers.

Methods: A total of N=143 participants (n=55 in Experiment 1 and n=88 in Experiment 2) were ostracized from a web-conference by two other individuals. Facial expressions of participants during the exclusion period were coded using EMFACS and compared to self-reported reactions to ostracism and the sources of the ostracism.

Results: Ostracized individuals showed significant levels of both Duchenne (genuine) and non-Duchenne (social) smiling, despite finding ostracism highly aversive, reporting more negative attitudes towards the ostracizing confederates, and (in Experiment 2) higher levels of negative affect. Experiment 2 showed evidence of a self-regulation and display management function of smiling during ostracism in that participants who exhibited more Duchenne smiling during their exclusion also reported higher levels of positive emotion after the ostracism, and were also rated by a group of judges as experiencing more amusement at their exclusion.

Conclusion: The web conferencing paradigm used in this study provides an ecologically valid method to study the management of expressive behavior during aversive interpersonal experiences, adding to the existing evidence of facial display management during other types of distressing experience.

Neural and cognitive correlates of stigma and social rejection in individuals with Serious Mental Illness (SMI): A systematic review of the literature

Stigma and self-stigma are major issues for people with Serious Mental Illness (SMI). This review's aims were to determine the cognitive and neural processes underlying the effects of stigma and social rejection in people with SMI. A stepwise systematic literature review (PRISMA) was conducted by searching PubMed, Medline and Web of Science using the following keywords: "cyberball" OR "stereotype threat" OR "implicit association test" AND "mental illness". The articles included met the following criteria: (a) reporting on social rejection, stigma or self-stigma (b) diagnosis of SMI (c) available data on the underlying mechanisms. Our search on July 31th 2018 found in 955 articles on PubMed and 3,362 on Web of Science. Hypersensitivity to acute social rejection was found and associated with more self-related negative emotions and more dysfunctional emotion regulation strategies. People with SMI under-performed in cognitive tasks when confronted with stigma. Stigma resistance was described with its neural correlates. Psychiatric symptoms, duration of illness and baseline non-specific distress influenced the response to acute social rejection or stigma. The samples, methods, and reported outcomes were heterogeneous and difficult to compare. Future studies should investigate the associations between self-stigma and responses to acute and chronic social rejection.

Low positive affect display mediates the association between borderline personality disorder and negative evaluations at zero acquaintance

BACKGROUND

Several recent studies have demonstrated that naïve raters tend to evaluate individuals with Borderline Personality Disorder (BPD) negatively at zero-acquaintance (i.e., in a 'first impression' type situation, where the rater has no knowledge of the individual and no prior interactions with them). Specifically, individuals with BPD were evaluated as less trustworthy, likeable, and cooperative than healthy participants (HCs). Based on previous impression formation studies, we hypothesized that the non-verbal cues positive affect display, negative affect display, and eye contact contribute to negative first impressions of those with BPD.

METHODS

To address this question, we recruited 101 participants that rated the degree of positive affect display, negative affect display, and eye contact in 52 videos of age-and gender-matched BPD and HC participants. We hypothesized that low positive affect display, high negative affect display, and eye contact would mediate the association between group (BPD vs. HC) and ratings of trustworthiness, likeability, and cooperativeness.

RESULTS

Ratings for positive affect display were significantly lower and those for negative affect display significantly higher for BPD versus HC targets, whereas eye contact did not differ significantly between groups. In multiple mediation models, positive affect display significantly mediated the association between group and trustworthiness/likeability, whereas negative affect display only mediated the association between group and likeability. None of the individual cues was a significant mediator of the association between group and cooperation.

CONCLUSIONS

We emphasize therapeutic possibilities to improve positive affect display -and thus overall first impressions- to increase the chances of forming social bonds for BPD individuals.

Conceptual Models of Borderline Personality Disorder, Part 2: A Process Approach and Its Implications

In part 2, the authors argue for a greater focus on a process approach to conceptualizing borderline personality disorder (BPD). The studies reviewed highlight contextual aspects of the pathology, specifically the affective and relational conditions under which BPD features become evident. The authors identify at what level in a complex social cognitive process the pathology may emerge. The implications of these findings for future model conceptualization are discussed, including the centrality of understanding BPD as an emergent phenomenon that cannot be reduced to single explanatory dimensions. The implications of these models for assessment, research, and treatment of BPD are discussed.

Exclusion-Proneness in Borderline Personality Disorder Inpatients Impairs Alliance in Mentalization-Based Group Therapy

Interpersonal sensitivity, particularly threat of potential exclusion, is a critical condition in borderline personality disorder (BPD) which impairs patients’ social adjustment. Current evidence-based treatments include group components, such as mentalization-based group therapy (MBT-G), in order to improve interpersonal functioning. These treatments additionally focus on the therapeutic alliance since it was discovered to be a robust predictor of treatment outcome. However, alliance is a multidimensional factor of group therapy, which includes the fellow patients, and may thus be negatively affected by the exclusion-proneness of BPD patients. The aim of this pilot study was to examine the predictive value of threat of social exclusion for the therapeutic alliance in MBT-G. In the first part of the study, social exclusion was experimentally induced in 23 BPD inpatients and 28 healthy subjects using the Cyberball paradigm, a virtual ball tossing game. The evoked level of threat was measured with the Need-Threat Scale (NTS) which captures four dimensions of fundamental human needs, i.e., the need for belongingness, for self-esteem, for control, and for a meaningful existence. In the second part of the study, therapeutic alliance was measured on three dimensions, the therapists, the fellow patients and the group as a whole, using the Group-Questionnaire (GQ-D). BPD patients scored higher in their level of threat according to the NTS in both, the inclusion and the exclusion condition. The level of threat after exclusion predicted impairments of the therapeutic alliance in MBT-G. It was associated with more negative relationships, lower positive bonding and a lower positive working alliance with the fellow patients and lower positive bonding to the group as a whole whilst no negative prediction of the alliance to the therapists was found. Consequently, our translational study design has shown that Cyberball is an appropriate tool to use as an approach for clinical questions. We further conclude that exclusion-proneness in BPD is a critical feature with respect to alliance in group treatments. In order to neutralize BPD patients’ exclusion bias, therapists may be advised to provide an “inclusive stance,” especially in initial sessions. It is also recommendable to strengthen patient to patient relations.

Feeling excluded no matter what? Bias in the processing of social participation in borderline personality disorder

Background

Patients with Borderline Personality Disorder (BPD) feel ostracized even when they are included. This might be due to a biased processing of social participation in BPD. We examined whether patients with BPD also process social overinclusion in a biased manner, i.e., whether they feel ostracized even when the degree of social participation is increased.

Methods

An EEG-compatible version of Cyberball was used to investigate the effects of inclusion and overinclusion (33% vs. 45% ball receipt) on perceived ostracism, need threat and P3 amplitude, an EEG indicator for expectancy violation. Twenty-nine patients with BPD, 28 patients with Social Anxiety Disorder (SAD) and 28 healthy controls (HC) participated.

Results

The P3 amplitude was enhanced for patients with BPD and SAD compared to HCs independent of condition. Both patient groups reported more perceived ostracism relative to HCs in the inclusion but not in the overinclusion condition. Only patients with BPD reported stronger need threat in both conditions.

Conclusions

The EEG results imply that being socially included violates the expectations of patients with BPD, irrespective of the actual degree of social participation. However, when overincluded, patients with BPD no longer feel ostracized. Except for need threat, patients with SAD might show a comparable bias in the processing of social participation as patients with BPD.

The Impact of Social Exclusion on "Reading the Mind in the Eyes" Performance in Relation to Borderline Personality Disorder Features

In this study we used the Reading the Mind in the Eyes Test (RMET) to explore facial emotion recognition in borderline personality disorder (BPD). We also used Cyberball, a computerized task designed to mimic social ostracism, to examine the response of BPD-feature participants to social exclusion. Seventeen individuals with BPD features were compared to 16 healthy controls on RMET performance pre- and post-exclusion via Cyberball. Our results revealed a significant interaction between BPD-feature status and RMET performance in relation to neutral stimuli following a social exclusion experience. BPD participants' ability to correctly identify neutral faces significantly decreased following exclusion. This finding suggests that once an individual with BPD features experiences a social exclusion event, his or her objectivity decreases and affective valence is ascribed to stimuli previously perceived as neutral. Our results may help to explain, in part, the social instability seen in BPD.

Models of borderline personality disorder: recent advances and new perspectives

PURPOSE OF REVIEW

The purpose of this article is to review the most relevant conceptual models of borderline personality disorder (BPD), with a focus on recent developments in this area.

RECENT FINDINGS

Several conceptual models have been proposed with the aim of better understanding BPD: the borderline personality organization, emotion dysregulation, reflective (mentalization) dysfunction, interpersonal hypersensitivity and hyperbolic temperament models. These models have all been supported to some extent and their common components include disorganized attachment and traumatic early experiences, emotion dysregulation, interpersonal sensitivity and difficulties with social cognition. An attempt to integrate some components of the conceptual models of BPD has resulted in an emerging new perspective, the interpersonal dysphoria model, which emphasizes dysphoria as an overarching phenomenon that connects the dispositional and situational aspects of BPD.

SUMMARY

Various conceptual models have expanded our understanding of BPD, but it appears that further development entails theoretical integration. More research is needed to better understand interactions between various components of BPD, including the situational factors that activate symptoms of BPD. This will help develop therapeutic approaches that are more tailored to the heterogeneous psychopathology of BPD.

Reduced white matter integrity in borderline personality disorder: A diffusion tensor imaging study

BACKGROUND

Borderline personality disorder (BPD) has a pervasive pattern of instability in interpersonal relationships, self-image, and emotions. BPD may be linked to an abnormal brain anatomy, but little is known about possible impairments of the white matter microstructure in BPD or their relationship with impulsivity or risky behaviors. The aims of the present study were to explore the relationship between BPD and diffusion tensor imaging (DTI) parameters and psychological tests.

METHODS

We evaluated 35 un-medicated BPD patients in a medication-free state and 50 healthy controls (HCs). We performed DTI tractography in BPD patients and HCs. The Childhood Trauma Questionnaire (CTQ), Profile of Mood State (POMS), State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI), Social Adaptation Self-Evaluation Scale (SASS), and Depression and Anxiety Cognition Scale (DACS) were administered to BPD patients and HCs.

RESULTS

A tract-based spatial statistics (TBSS) revealed that the BPD group had three clusters with a significantly lower axial diffusivity (AD) than the HC group: one located mainly in the cingulum and the other mainly in the inferior front-occipital fasciculus and inferior longitudinal fasciculus. Regarding the AD values, one cluster correlated negatively and significantly with POMS (Depression) and it was located in the cingulum, while another cluster correlated positively and significantly with DACS (Future Denial) and it was located in the inferior front-occipital fasciculus (IFOF).

LIMITATIONS

The small sample size of this study prevents us from forming any definitive conclusions, meaning that more studies are needed to confirm our findings. We are unable to generalize our findings to include other ethnic groups.

CONCLUSIONS

Our results suggested that hypo-metabolism in a front-limbic network dysfunction is characterized by the cingulum and a front-occipital network dysfunction characterized by the occipital lobe, while an occipital-temporal network dysfunction characterized by the inferior longitudinal fasciculus.

Interpersonal Threat Sensitivity in Borderline Personality Disorder: An Eye-Tracking Study

Threat sensitivity is a prominent predictor of interpersonal dysfunctions in borderline personality disorder (BPD), leading to intense, aversive feelings of threat and eventually dysfunctional behaviors, such as aggression. In the present study, BPD patients and healthy volunteers classified angry, fearful, neutral, and happy faces presented for 150 ms or 5,000 ms to investigate initial saccades and facial scanning. Patients more often wrongly identified anger, responded slower to all faces, and made faster saccades towards the eyes of briefly presented neutral faces and slower saccades away from fearful eyes compared with healthy volunteers. Latency of initial saccades and fixation duration correlated negatively with the patients' aggressiveness. Supporting previous results, BPD patients did not experience general deficits in facial emotion processing, but a specific hypersensitivity for and deficits in detailed evaluation of threat cues, which was particularly enhanced in aggressive patients. Interventions might benefit from relocating attention towards positive information and detailed evaluation of social cues.

Attachment representations, patterns of emotion regulation, and social exclusion in patients with chronic and episodic depression and healthy controls

BACKGROUND

The experience of social exclusion (ostracism) is linked to the etiology and maintenance of depression. Most individuals experience emotional stress in states of social exclusion. Insecurely attached individuals, especially with an unresolved trauma, show maladaptive coping in response to social stress. The present study examines (a) the differences with regards to attachment representations in episodic (ED) and chronic depressive (CD) inpatients and (b) how ostracism affects their emotional reactions.

METHODS

Patients with CD (n=29) and ED (n=23) and healthy control subjects (n=29) were interviewed using the Adult Attachment Projective Picture System (AAP), a valid measure to assess attachment representation; and played a virtual ball tossing game simulating social exclusion (Cyberball). Multiple depression-related risk and protective factors were considered. We hypothesized that CD patients show the most severe attachment disorganization and are emotionally most affected by the social exclusion situation. Moreover, we explored the interaction between ostracism and attachment.

RESULTS

Contradicting our hypotheses, ED and CD individuals were almost akin with regards to their attachment insecurity/disorganization and reactions to Cyberball. An emotionally altered reaction to social exclusion was identified in the insecure-disorganized depressive subgroup.

LIMITATIONS

Small sample size hampering further subgroup analyses. The ED sample may include single CD subjects with recent manifestation.

CONCLUSIONS

The pattern of emotion regulation in the depressive groups matches with findings from clinical studies, including attachment research. The relationship between attachment representations and ostracism should be further investigated in larger samples of depressive individuals.

Processing of information about future life events in borderline personality disorder

Borderline Personality Disorder (BPD) is associated with negative self-images. However, it has remained underexplored whether BPD patients hold negative views of their personal future. When receiving information about possible future live events, healthy participants tend to update their estimates more toward desirable than toward undesirable information. Here, we test whether BPD patients (n=21) process information about their future in a more negative fashion than healthy controls (n=79). Participants rated their probability of experiencing 45 adverse life events-before and after receiving statistical information about the average probability of these events. BPD patients first estimated their probability of experiencing negative life events higher than healthy controls. However, after receiving information about the life events the estimates of two groups did not differ. Both groups updated their estimates more toward desirable than toward undesirable information. Thus, our findings suggest a nuanced picture. At the outset, BPD patients appear pessimistic but they might be able to overcome their pessimism when provided with relevant information. Taken together, BPD patients were initially more pessimistic about their personal future than healthy controls. Both groups showed positively biased updating without evidence for differences in BPD patients.

Neural correlates of fears of abandonment and rejection in borderline personality disorder

Background: Borderline personality disorder (BPD) is a prevalent and disabling psychiatric condition commonly associated with early life adversity. Social difficulties are a prominent symptom of BPD, particularly a fear of abandonment and rejection. There has recently been a growing interest in the neural basis of these social symptoms and their relationship to early experience.  Methods: In the current study, we examined social brain function and learning in BPD using functional MRI. Participants with BPD (n=20) and healthy controls (n=16) completed a computerized parametric social exclusion task (the “Cyberball” task). Brain activation was compared between groups and related to social symptom status and experiences of childhood trauma. Additional analyses were conducted using a reinforcement learning model treating social inclusion as a rewarding event.  Results: Participants with BPD demonstrated a group effect of decreased right temporoparietal junction (TPJ) activation (p < 0.013, FWE-corrected). Increased fear of abandonment in BPD was associated with reduced inclusion-related activation of the inferior frontal gyrus (p = 0.003, FWE-corrected). Across all participants, TPJ inclusion-related activation was modified by prior experience of childhood physical neglect (p < 0.001, FWE-corrected). Reinforcement learning modelling revealed decreased midbrain responses to social inclusion in BPD participants (p = 0.028, FWE-corrected within midbrain mask), with decreased anticipatory midbrain activation in anticipation of social inclusion specifically associated with fears of abandonment (p = 0.019, FWE-corrected within a midbrain mask).  Conclusions: The findings demonstrate alterations in social brain function and social reinforcement learning in BPD, which are influenced by both early life experience and symptom status.

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

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

Differential neural processing of social exclusion in adolescents with non-suicidal self-injury: An fMRI study

Non-suicidal self-injury (NSSI) is highly prevalent in adolescence and has been suggested as an autonomous diagnosis in the Diagnostic and Statistical Manual (DSM-5). Social rejection is as potential risk-factor for NSSI and depression in adolescence. Objectives of this study were to identify differences in neural processing of social rejection in depressed adolescents with and without co-morbid NSSI and healthy controls. Participants were 28 depressed adolescents (14 with co-morbid NSSI, 79% females) and 15 healthy controls, with an average age of 15.2 years (SD=1.8). Social exclusion was implemented using the Cyberball paradigm 'Cyberball' during functional magnetic resonance imaging (fMRI). All participants reported feelings of social exclusion after fMRI scanning. Investigating the effects of NSSI, we found that depressed adolescents with NSSI showed relatively enhanced activation of the medial prefrontal cortex (mPFC) and the ventrolateral prefrontal cortex (vlPFC) compared to depressed adolescents without NSSI and also compared to healthy controls. Results point towards divergent processing of social exclusion in depressed adolescents with NSSI as compared to adolescents with mere depression in brain regions previously related to the processing of social exclusion. This finding of distinct neurophysiological responses may stimulate further research on individual treatment approaches.

Virtueller sozialer Ausschluss

Zusammenfassung. Theoretischer Hintergrund: Soziale Ausgrenzung bzw. Ostrazismus bedroht das Gefühl menschlicher Existenz, da soziale Zugehörigkeit eines unserer psychologischen Grundbedürfnisse ist. Fragestellung: Der Einfluss verschiedener Experimentalbedingungen (Erhöhung der Mitspieleranzahl, Hinzufügen von Fotos, Stimmungsinduktion) im Cyberball-Paradigma in einer Stichprobe von Jugendlichen. Dieser wird anhand eines Gefühlsratings im prä-post Vergleich sowie vier psychologischen Grundbedürfnissen (Bedeutsame Existenz, Zugehörigkeit, Kontrolle und Selbstwert) untersucht. Darüber hinaus wird explorativ der Einfluss von Emotionsregulationsschwierigkeiten und Depressions-Angst-Stress-Symptomen auf den Effekt von Cyberostrazismus mit einbezogen. Methode: Bei 117 Jugendlichen zwischen 12 und 18 Jahren wurde Cyberostrazismus induziert. Ergebnisse: Nach dem Cyberballspiel zeigten Jugendliche eine signifikante Steigerung von Ärger (d = 0.61) und Traurigkeit (d = 0.57) sowie einer Reduktion von Freude (d = 0.55) und Aufregung (d = 0.47). Eine Erhöhung der Mitspielerzahl ergab eine geringere Beeinträchtigung psychologischer Grundbedürfnisse, im Vergleich zu den anderen drei Experimentalbedingungen. Depressions-Angst-Stress-Symptome und Emotionsregulationsschwierigkeiten standen im Zusammenhang mit einer signifikant stärkeren Minderung des Selbstwerts mit großer Effektstärke (f 2 = .43). Schlussfolgerung: Die Induktion von Cyberostrazimus zeigte sich in dieser Studie erfolgreich. Die erweiterten Experimentalbedingungen ergaben sowohl auf Gefühlsebene, als auch in einer Minderung psychologischer Grundbedürfnisse keine Vorteile im Vergleich zur Basisversion. Insgesamt verdeutlichen die Ergebnisse die negativen psychischen Auswirkungen von Cyberostrazismus sowie den Einfluss von Psychopathologie i.S. eines geringeren Selbstwerts nach der Induktion von Cyberostrazimus.

Facial expression to emotional stimuli in non-psychotic disorders: A systematic review and meta-analysis

Facial expression of emotion is crucial to social interaction and emotion regulation; therefore, altered facial expressivity can be a contributing factor in social isolation, difficulties with emotion regulation and a target for therapy. This article provides a systematic review and meta-analysis of the literature on automatic emotional facial expression in people with non-psychotic disorders compared to healthy comparison groups. Studies in the review used an emotionally salient visual induction method, and reported on automatic facial expression in response to congruent stimuli. A total of 39 studies show alterations in emotional facial expression across all included disorders, except anxiety disorders. In depression, decreases in facial expression are mainly evident for positive affect. In eating disorders, a meta-analysis showed decreased facial expressivity in response to positive and negative stimuli. Studies in autism partially support generally decreased facial expressivity in this group. The data included in this review point towards decreased facial emotional expressivity in individuals with different non-psychotic disorders. This is the first review to synthesise facial expression studies across clinical disorders.

Social feedback processing in borderline personality disorder

BACKGROUND

Patients with borderline personality disorder (BPD) show negative and unstable self- and other-evaluations compared to healthy individuals. It is unclear, however, how they process self- and other-relevant social feedback. We have previously demonstrated a positive updating bias in healthy individuals: When receiving social feedback on character traits, healthy individuals integrate desirable more than undesirable feedback. Here, our aim was to test whether BPD patients exhibit a more negative pattern of social feedback processing.

METHOD

We employed a character trait task in which BPD patients interacted with four healthy participants in a real-life social interaction. Afterwards, all participants rated themselves and one other participant on 80 character traits before and after receiving feedback from their interaction partners. We compared how participants updated their ratings after receiving desirable and undesirable feedback. Our analyses included 22 BPD patients and 81 healthy controls.

RESULTS

Healthy controls showed a positivity bias for self- and other-relevant feedback as previously demonstrated. Importantly, this pattern was altered in BPD patients: They integrated undesirable feedback for themselves to a greater degree than healthy controls did. Other-relevant feedback processing was unaltered in BPD patients.

CONCLUSIONS

Our study demonstrates an alteration in self-relevant feedback processing in BPD patients that might contribute to unstable and negative self-evaluations.

ESCAP Expert Article: borderline personality disorder in adolescence: an expert research review with implications for clinical practice

Borderline personality disorder (BPD) has onset in adolescence, but is typically first diagnosed in young adulthood. This paper provides a narrative review of the current evidence on diagnosis, comorbidity, phenomenology and treatment of BPD in adolescence. Instruments available for diagnosis are reviewed and their strengths and limitations discussed. Having confirmed the robustness of the diagnosis and the potential for its reliable clinical assessment, we then explore current understandings of the mechanisms of the disorder and focus on neurobiological underpinnings and research on psychological mechanisms. Findings are accumulating to suggest that adolescent BPD has an underpinning biology that is similar in some ways to adult BPD but differs in some critical features. Evidence for interventions focuses on psychological therapies. Several encouraging research studies suggest that early effective treatment is possible. Treatment development has just begun, and while adolescent-specific interventions are still in the process of evolution, most existing therapies represent adaptations of adult models to this developmental phase. There is also a significant opportunity for prevention, albeit there are few data to date to support such initiatives. This review emphasizes that there can be no justification for failing to make an early diagnosis of this enduring and pervasive problem.

Pain Processing after Social Exclusion and Its Relation to Rejection Sensitivity in Borderline Personality Disorder

OBJECTIVE

There is a general agreement that physical pain serves as an alarm signal for the prevention of and reaction to physical harm. It has recently been hypothesized that "social pain," as induced by social rejection or abandonment, may rely on comparable, phylogenetically old brain structures. As plausible as this theory may sound, scientific evidence for this idea is sparse. This study therefore attempts to link both types of pain directly. We studied patients with borderline personality disorder (BPD) because BPD is characterized by opposing alterations in physical and social pain; hyposensitivity to physical pain is associated with hypersensitivity to social pain, as indicated by an enhanced rejection sensitivity.

METHOD

Twenty unmedicated female BPD patients and 20 healthy participants (HC, matched for age and education) played a virtual ball-tossing game (cyberball), with the conditions for exclusion, inclusion, and a control condition with predefined game rules. Each cyberball block was followed by a temperature stimulus (with a subjective pain intensity of 60% in half the cases). The cerebral responses were measured by functional magnetic resonance imaging. The Adult Rejection Sensitivity Questionnaire was used to assess rejection sensitivity.

RESULTS

Higher temperature heat stimuli had to be applied to BPD patients relative to HCs to reach a comparable subjective experience of painfulness in both groups, which suggested a general hyposensitivity to pain in BPD patients. Social exclusion led to a subjectively reported hypersensitivity to physical pain in both groups that was accompanied by an enhanced activation in the anterior insula and the thalamus. In BPD, physical pain processing after exclusion was additionally linked to enhanced posterior insula activation. After inclusion, BPD patients showed reduced amygdala activation during pain in comparison with HC. In BPD patients, higher rejection sensitivity was associated with lower activation differences during pain processing following social exclusion and inclusion in the insula and in the amygdala.

DISCUSSION

Despite the similar behavioral effects in both groups, BPD patients differed from HC in their neural processing of physical pain depending on the preceding social situation. Rejection sensitivity further modulated the impact of social exclusion on neural pain processing in BPD, but not in healthy controls.

Effects of social exclusion on emotions and oxytocin and cortisol levels in patients with chronic depression

OBJECTIVE

Patients with chronic depression (CD) experience a high burden of disease, severe co-morbidity, and increased mortality. Although interpersonal dysfunction is a hallmark of CD, the underlying mechanisms are largely unexplored. Oxytocin (OT) has been proposed to play a crucial role in the social deficits of mental disorders and has been found to be dysregulated after social exclusion (ostracism) in patients with borderline personality disorder. This study investigated how social exclusion affects emotions, OT levels, and cortisol (CT) levels in CD patients.

METHOD

Twenty-one patients diagnosed with CD and 21 healthy controls (HC) matched for gender, age, and education underwent repeated neuroendocrine measurements in a standardized laboratory setting while playing Cyberball, a virtual ball-tossing game that mimics a social exclusion situation. Emotional reactions, plasma OT and cortisol levels were assessed at baseline and 5, 15, and 40 min after Cyberball.

RESULTS

At baseline, there were no group differences in OT levels. Immediately after playing Cyberball, plasma OT levels showed divergent changes in CD patients and HC; the difference in direction of change was significant with a reduction in CD patients compared to HC (p = .035*); CT levels did not differ between groups at any time point, but decreased over time. Patients showed more threatened emotional needs and increased negative emotions, especially anger and resentment, and showed higher sensitivity to ambiguous threat of social exclusion than healthy controls.

CONCLUSIONS

CD patients react to ostracism with pronounced negative emotions. The reduction in OT levels in CD patients after social exclusion may contribute to their interpersonal dysfunction and their difficulty in coping adequately with aversive social cues.

Social cognition

Social cognition is a major problem underlying deficiencies in interpersonal relationships in several psychiatric populations. And yet there is currently no gold standard for pharmacological treatment of psychiatric illness that directly targets these social cognitive areas. This chapter serves to illustrate some of the most innovative attempts at pharmacological modulation of social cognition in psychiatric illnesses including schizophrenia, borderline personality disorder, autism spectrum disorders, antisocial personality disorder and psychopathy, social anxiety disorder, and posttraumatic stress disorder. Pharmacological modulation includes studies administering oxytocin, ecstasy (MDMA), modafinil, methylphenidate, and D-cycloserine. Furthermore, some background on social cognition research in healthy individuals, which could be helpful in developing future treatments, is provided as well as the potential for each drug as a long-term treatment option.

Patient-reported outcomes in borderline personality disorder

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

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

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

Interpersonal functioning in borderline personality disorder: a systematic review of behavioral and laboratory-based assessments

It is widely accepted that interpersonal problems are a central area of difficulty for those with borderline personality disorder (BPD). However, empirical elucidation of the specific behaviors, or patterns of behaviors, characterizing interpersonal dysfunction or dissatisfaction with relationships in BPD is limited. In this paper, we review the literature on interpersonal functioning of individuals with BPD by focusing on studies that include some assessment of interpersonal functioning that is not solely self-report; that is, studies with either behavioral laboratory tasks or manipulation of interpersonal stimuli in a controlled laboratory setting were included. First, we review the literature relevant to social cognition, including perceptual biases, Theory of Mind/empathy, and social problem-solving. Second, we discuss research that assesses reactivity to interpersonal stressors and interpersonal aggression in BPD. Next, we review the literature on trust and cooperation among individuals with BPD and controls. Last, we discuss the behavior of mothers with BPD in interactions with their infants. In conclusion, we specify areas of difficulty that are consistently identified as characterizing the interpersonal behaviors of those with BPD and the relevant implications. We also discuss the difficulties in synthesizing this body of literature and suggest areas for future research.