Social feedback processing in borderline personality disorder

Mechanism-based modular psychotherapy versus cognitive behavioural therapy for adolescents and young adults with childhood trauma experiences: study protocol for a feasibility trial within the German Center for Mental Health

INTRODUCTION

Patients with mental disorders and a history of childhood trauma show an early onset of psychopathology and often a poor response to standard disorder-specific treatments. They represent a patient group which requires more personalised interventions targeting the transdiagnostic mechanisms related to early trauma and its functional consequences. The mechanism-based modular psychotherapy (MeMoPsy) approach is conceptualised as an innovative framework for psychotherapy development. It comprises independent, flexibly applicable interventions from various theoretical backgrounds and evidence-based programmes within a systematic treatment algorithm, thereby tailoring module selection to the specific needs of traumatised adolescents.

METHODS AND ANALYSIS

In a randomised controlled feasibility trial (RCT), N=80 outpatients between 15 and 25 years of age diagnosed with various mental disorders will receive 28 individual sessions with MeMoPsy or standard cognitive behavioural therapy. MeMoPsy includes a basic module that addresses trauma history and three additional modules focusing on functional impairments known to be associated with childhood trauma: rejection sensitivity, emotion regulation and relationship difficulties. These modules are selected based on a self-report algorithm. Techniques from mentalisation-based therapy, cognitive behavioural analysis system of psychotherapy, dialectical behaviour therapy and systemic therapy are integrated in this personalised modular procedure. This proof-of-concept study aims to provide initial evidence for acceptability, feasibility and changes in self-rated and diagnostician-rated psychopathology (post-treatment and 3 months follow-up) of MeMoPsy and elucidate the mechanisms of change using psychotherapy process research, Ecological Momentary Assessment and functional magnetic resonance imaging (fMRI).

ETHICS AND DISSEMINATION

This RCT obtained approval from independent ethics committees of participating centres and is accompanied by a data and safety monitoring board. Findings will be communicated within the research community as well as with patients and the public by the dissemination strategies of the German Center for Mental Health.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register DRKS00034058.

Selective Integration of Social Feedback Promotes a Stable and Positively Biased Self-Concept

Understanding self-concept dynamics is crucial given its generalized impact on our well-being. However, how we integrate information into our self-representations to promote a positively biased, yet progressively stable self-concept is a question that remains unanswered. In a series of four experiments, we refined a belief updating task to investigate how participants integrate social feedback depending on its valence and self-congruence. Experiment 1 indicated that the lack of control of an initial positive bias in participants self-concept might have masked valence and congruence effects in recent works. After implementing methodological adjustments (Experiments 2 and 3) we found that the integration of social feedback was strongly driven by feedback self-congruence and moderately driven by feedback valence. By synthesizing insights from social, personality, and cognitive psychology, this study advances the understanding of self-concept dynamics during social feedback processing. Our conceptual and methodological advancements offer a new lens for reinterpreting previous findings.

Towards an expanded neurocognitive account of ketamine's rapid antidepressant effects

Ketamine is an N-methyl-D-aspartate receptor antagonist that has shown effectiveness as a rapidly acting treatment for depression. Although advances have been made in understanding ketamine's antidepressant pharmacological and molecular mechanisms of action, the large-scale neurocognitive mechanisms driving its therapeutic effects are less clearly understood. To help provide such a framework, we provide a synthesis of current evidence linking ketamine treatment to the modulation of brain systems supporting reward processing, interoception, and self-related cognition. We suggest that ketamine's antidepressant effects are, at least in part, driven by dynamic multi-level influences across these key functional domains.

Beyond the Positivity Bias: The Processing and Integration of Self-Relevant Feedback Is Driven by Its Alignment With Pre-Existing Self-Views

Our self-concept is constantly faced with self-relevant information. Prevailing research suggests that information's valence plays a central role in shaping our self-views. However, the need for stability within the self-concept structure and the inherent alignment of positive feedback with the pre-existing self-views of healthy individuals might mask valence and congruence effects. In this study (N = 30, undergraduates), we orthogonalized feedback valence and self-congruence effects to examine the behavioral and electrophysiological signatures of self-relevant feedback processing and self-concept updating. We found that participants had a preference for integrating self-congruent and dismissing self-incongruent feedback, regardless of its valence. Consistently, electroencephalography results revealed that feedback congruence, but not feedback valence, is rapidly detected during early processing stages. Our findings diverge from the accepted notion that self-concept updating is based on the selective incorporation of positive information. These findings offer novel insights into self-concept dynamics, with implications for the understanding of psychopathological conditions.

A second chance for first impressions: evidence for altered impression updating in borderline personality disorder

BACKGROUND

Individuals with borderline personality disorder (BPD) frequently alter between idealizing and devaluing other persons, which has been linked to an increased tendency to update self-relevant beliefs and impressions. We hypothesized that increased impression updating could stem from reduced attitude contextualization, i.e., a process in which impression-disconfirming information is linked to contextual cues.

METHODS

Individuals diagnosed with BPD and controls (recruited online, with unknown diagnostic status) completed an impression formation paradigm. They first learned about the positive or negative behaviors of others in one Context A (e.g., Person 1 is helpful), followed by learning about behaviors of the opposite valence in a second Context B (Person 1 is rude). We also manipulated between participants whether the observed behaviors were directed toward the study participants (self-relevant) or, more generally, at other people (other-relevant). The contexts were marked by differently-colored backgrounds (e.g., yellow vs. blue), to avoid influences of prior knowledge or experiences. After exposure to information in both contexts, participants rated their impressions of the persons in Context A, Context B, and, crucially, a previously unknown Context C (white background). We examined whether the initial or an updated impression (re-)emerged in Context C.

RESULTS

Initial impressions remained stable and dominated the ratings of controls across contexts A, B, and C for both self-relevant and other-relevant behaviors, consistent with contextualizing impression-disconfirming information. As expected, however, individuals with BPD only showed updated impression ratings in Context C for self-relevant behaviors, consistent with the assumed reduced tendency to contextualize impression-disconfirming self-relevant information. Further exploratory analyses suggest that more severe BPD symptoms predicted more pronounced impression updating in the self-relevant condition.

CONCLUSIONS

The findings help to illuminate the mechanisms underlying interpersonal problems in individuals with BPD. People with BPD are not just more inclined to discard positive first impressions but to re-evaluate disliked others when they behave positively, contributing to the volatility of interactions with others. Contextualization has known and modifiable antecedents, and the study may thus provide potential targets for therapeutic intervention. Future studies will need to replicate the findings with specified controls.

How negative self-views may interfere with building positive relationships: An experimental analogue of identity dysfunction in borderline personality disorder

INTRODUCTION

A disturbed, negative sense of self is associated with various interpersonal difficulties and is characteristic of disorders such as borderline personality disorder (BPD). Negative self-views may affect an individuals' ability to build positive relationships, including a therapeutic relationship. However, it is not yet well understood how identity disturbances give rise to interpersonal difficulties. Using an experimental analogue design, we tested whether identity disturbances are associated with interpersonal difficulties.

METHODS

Participants were university students (N = 43, age M = 20.51 (SD = 3.08), women N = 32 (74.4%)) who reported moderate to high levels of BPD features, with 34.9% reporting significant BPD features as measured by the Borderline scale of the Personality Assessment Inventory (PAI-BOR). In a within-subject experimental paradigm using a Social Feedback Task, participants received negative, intermediate, and positive evaluations, supposedly from a panel. Using multilevel models, we tested whether negative self-views were associated with how much the participants liked, trusted, and felt close to each of the three panel members who provided either predominantly negative, intermediate, or positive feedback.

RESULTS

People with more negative self-views reported lower mood in response to positive feedback. In addition, where people with more positive self-views felt better when receiving feedback that was congruent with their self-views, people with more negative self-views did not report a better mood. Importantly, people with negative self-views felt lower desire to affiliate with the member who provided predominantly positive feedback. Affiliation was not affected when feedback was given by the negative member and intermediate member to those with negative self-views.

CONCLUSIONS

The findings validated that those with more negative self-views anticipated and expected more negative responses from others. Negative self-views, as relevant for BPD, may explain how people relate differently to those giving different types of feedback. Pervasive negative self-views may interfere with building new relationships including the therapeutic alliance. It may be helpful for clinicians to be aware of the potential challenges around creating a supportive therapeutic relationship for patients with negative self-views. Overly positive affirmations made by clinicians may inadvertently lower the patient's mood and may impede alliance formation.

Borderline personality disorder features are associated with inflexible social interpretations

BACKGROUND

Borderline personality disorder (BPD) is thought to involve aberrant social learning, including impaired revision of social interpretations with new evidence (social interpretation inflexibility). However, this topic has received little empirical attention outside of specific literatures, such as moral inference or behavioral economics. Further, the contribution of comorbid depression to BPD-related interpretation inflexibility has not yet been assessed.

METHODS

In two independent samples (Study 1: N = 213; Study 2: N = 210, oversampled for BPD features), we assessed the associations between BPD symptoms, depressive symptoms, and task-based measures of social interpretation flexibility.

RESULTS

We found that BPD symptoms, particularly volatility of identity and relationships, were associated with less revision of social interpretations with both positive and negative evidence. Meanwhile, depressive symptoms were associated with a pattern of less revision of social interpretations with positive versus negative information.

LIMITATIONS

The use of cross-sectional, crowdsourced samples limits causal interpretations. Translation to clinical populations should be assessed in future studies.

CONCLUSIONS

Results suggest that inflexible social interpretations across valences may be a feature of BPD-related pathology, and could be connected to symptoms involving volatility in social contexts. Future studies should investigate whether treatments geared toward increasing the flexibility of social interpretations are effective in treating BPD symptoms, especially those involving interpersonal difficulties.

There is no belief update bias for neutral events: failure to replicate Burton et al. (2022)

In a recent paper, Burton et al. claim that individuals update beliefs to a greater extent when learning an event is less likely compared to more likely than expected. Here, we investigate Burton's et al.'s, findings. First, we show how Burton et al.'s data do not in fact support a belief update bias for neutral events. Next, in an attempt to replicate their findings, we collect a new data set employing the original belief update task design, but with neutral events. A belief update bias for neutral events is not observed. Finally, we highlight the statistical errors and confounds in Burton et al.'s design and analysis. This includes mis-specifying a reinforcement learning approach to model the data and failing to follow standard computational model fitting sanity checks such as parameter recovery, model comparison and out of sample prediction. Together, the results find little evidence for biased updating for neutral events.

Biased belief updating in depression

Cognitive approaches to depression have benefitted from recent research on belief updating, examining how new information is used to alter beliefs. This review presents recent advances in understanding various sources of bias in belief updating in depression. Specifically, research has demonstrated that people with depression have difficulty revising negative beliefs in response to novel positive information, whereas belief updating in depression is not related to an enhanced integration of negative information. In terms of mechanisms underlying the deficient processing of positive information, research has shown that people with depression use defensive cognitive strategies to devalue novel positive information. Furthermore, the disregard of novel positive information can be amplified by the presence of state negative affect, and the resulting persistence of negative beliefs in turn perpetuates chronically low mood, contributing to a self-reinforcing negative feedback loop of beliefs and affect. Synthesising previous research, this review proposes a coherent framework of when belief change is likely to occur, and argues that future research also needs to elucidate why people with depression hesitate to abandon negative beliefs. Recent insights from belief updating have not only improved the understanding of the psychopathology of depression, but also have the potential to improve its cognitive-behavioural treatment.

A neuro-computational social learning framework to facilitate transdiagnostic classification and treatment across psychiatric disorders

Social deficits are among the core and most striking psychiatric symptoms, present in most psychiatric disorders. Here, we introduce a novel social learning framework, which consists of neuro-computational models that combine reinforcement learning with various types of social knowledge structures. We outline how this social learning framework can help specify and quantify social psychopathology across disorders and provide an overview of the brain regions that may be involved in this type of social learning. We highlight how this framework can specify commonalities and differences in the social psychopathology of individuals with autism spectrum disorder (ASD), personality disorders (PD), and major depressive disorder (MDD) and improve treatments on an individual basis. We conjecture that individuals with psychiatric disorders rely on rigid social knowledge representations when learning about others, albeit the nature of their rigidity and the behavioral consequences can greatly differ. While non-clinical cohorts tend to efficiently adapt social knowledge representations to relevant environmental constraints, psychiatric cohorts may rigidly stick to their preconceived notions or overly coarse knowledge representations during learning.

The (un)learning of social functions and its significance for mental health

Social interactions are dynamic, context-dependent, and reciprocal events that influence prospective strategies and require constant practice and adaptation. This complexity of social interactions creates several research challenges. We propose a new framework encouraging future research to investigate not only individual differences in capacities relevant for social functioning and their underlying mechanisms, but also the flexibility to adapt or update one's social abilities. We suggest three key capacities relevant for social functioning: (1) social perception, (2) sharing emotions or empathizing, and (3) mentalizing. We elaborate on how adaptations in these capacities may be investigated on behavioral and neural levels. Research on these flexible adaptations of one's social behavior is needed to specify how humans actually "learn to be social". Learning to adapt implies plasticity of the relevant brain networks involved in the underlying social processes, indicating that social abilities are malleable for different contexts. To quantify such measures, researchers need to find ways to investigate learning through dynamic changes in adaptable social paradigms and examine several factors influencing social functioning within the three aformentioned social key capacities. This framework furthers insight concerning individual differences, provides a holistic approach to social functioning, and may improve interventions for ameliorating social abilities in patients.

Threat induction biases processing of emotional expressions

Threats can derive from our physical or social surroundings and bias the way we perceive and interpret a given situation. They can be signaled by peers through facial expressions, as expressed anger or fear can represent the source of perceived threat. The current study seeks to investigate enhanced attentional state and defensive reflexes associated with contextual threat induced through aversive sounds presented in an emotion recognition paradigm. In a sample of 120 healthy participants, response and gaze behavior revealed differences in perceiving emotional facial expressions between threat and safety conditions: Responses were slower under threat and less accurate. Happy and neutral facial expressions were classified correctly more often in a safety context and misclassified more often as fearful under threat. This unidirectional misclassification suggests that threat applies a negative filter to the perception of neutral and positive information. Eye movements were initiated later under threat, but fixation changes were more frequent and dwell times shorter compared to a safety context. These findings demonstrate that such experimental paradigms are capable of providing insight into how context alters emotion processing at cognitive, physiological, and behavioral levels. Such alterations may derive from evolutionary adaptations necessary for biasing cognitive processing to survive disadvantageous situations. This perspective sets up new testable hypotheses regarding how such levels of explanation may be dysfunctional in patient populations.

How childhood maltreatment alters perception and cognition - the predictive processing account of borderline personality disorder

Borderline personality disorder (BPD) is a severe mental disorder, comprised of heterogeneous psychological and neurobiological pathologies. Here, we propose a predictive processing (PP) account of BPD to integrate these seemingly unrelated pathologies. In particular, we argue that the experience of childhood maltreatment, which is highly prevalent in BPD, leaves a developmental legacy with two facets: first, a coarse-grained, alexithymic model of self and others - leading to a rigidity and inflexibility concerning beliefs about self and others. Second, this developmental legacy leads to a loss of confidence or precision afforded beliefs about the consequences of social behavior. This results in an over reliance on sensory evidence and social feedback, with concomitant lability, impulsivity and hypersensitivity. In terms of PP, people with BPD show a distorted belief updating in response to new information with two opposing manifestations: rapid changes in beliefs and a lack of belief updating despite disconfirmatory evidence. This account of distorted information processing has the potential to explain both the instability (of affect, self-image, and interpersonal relationships) and the rigidity (of beliefs about self and others) which is typical of BPD. At the neurobiological level, we propose that enhanced levels of dopamine are associated with the increased integration of negative social feedback, and we also discuss the hypothesis of an impaired inhibitory control of the prefrontal cortex in the processing of negative social information. Our account may provide a new understanding not only of the clinical aspects of BPD, but also a unifying theory of the corresponding neurobiological pathologies. We conclude by outlining some directions for future research on the behavioral, neurobiological, and computational underpinnings of this model, and point to some clinical implications of it.

Negativity in delayed affective recall is related to the borderline personality trait

The present study assessed selected factors that contribute to the recollection of emotional memories over time. Participants with high-trait borderline personality disorder (BPD) watched a randomly selected positive, negative, or neutral character in a video clip (stimulus) and were asked to recall the content immediately, then 2, 4, and 6 days later. In the final sample (N = 558, average age: 33 years, 65% female), general impression had the strongest effect on recall after accounting for the effect of current mood, extremity of the responses, and level of BPD, regardless of stimulus valence. The level of BPD had an effect only when negative evaluative wording (e.g., “guilty”) was used. In conclusion, people with high-trait BPD tend to remember negative stimuli more negatively over time (unlike neutral or positive stimuli), and this effect is mostly related to general impression.

No Evidence for the Involvement of Cognitive Immunisation in Updating Beliefs About the Self in Three Non-Clinical Samples

BACKGROUND

Cognitive immunisation against disconfirmatory evidence (i.e., devaluing expectation-disconfirming information through cognitive mechanisms) has recently been discussed as an obstacle to the revision of dysfunctional beliefs in mental disorders such as depression. Yet, it is unclear whether cognitive immunisation is also involved in belief updating in non-clinical samples.

METHODS

Using a three-group modulation protocol (promotion vs. inhibition of cognitive immunisation vs. control group), we examined how cognitive immunisation influences belief updating in response to performance feedback in three non-clinical samples. In Experiments 1 (N = 99) and 2 (N = 93), participants received unexpectedly negative feedback, whereas participants from Experiment 3 (N = 118) received unexpectedly positive feedback. Depressive symptoms and dispositional optimism were examined as additional predictors of belief updating.

RESULTS

In all experiments, participants adjusted their expectations in line with the feedback received, but this effect was not influenced by the cognitive immunisation manipulation. In Experiment 3, expectation change remained stable over 2 weeks. Depressive symptoms were associated with a reduced integration of positive feedback, but not with an increased sensitivity to negative feedback.

CONCLUSIONS

Whereas previous research has shown that cognitive immunisation contributes to persistent beliefs in clinical populations, the present findings suggest that it does not affect belief updating in non-clinical samples.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10608-021-10256-y.

Self-referential processing and perspective taking in patients with a borderline personality disorder

Divergent self- and other-referential processes play a particular role in the development and maintenance of borderline personality disorder (BPD). This study investigated self-referential processes in patients with BPD and age-matched controls. Participants performed a trait-judgment task, taking their own and the perspective of a close other person. Memory was assessed during recall of the previous choices. Results revealed over all more negative self-appraisals in patients than controls, which seemed due to making less positive self-referential choices rather than an increased choice of negative traits. Interestingly, taking another perspective, patients had a healthier, predominantly positive self-assessment, albeit still attenuated compared to controls. The characteristics of the appraisals were mirrored in memory performances. Moreover, self-esteem seems to be a potential protective factor, as self-appraisals were more positive with higher self-esteem. Altogether, this study shows significantly deviant self-referential processes in patients with BPD, suggesting that patients do not integrate what they believe others think about them into their self-concept.

Differential diagnosis of borderline personality disorder and bipolar disorder: Self-concept, identity and self-esteem

Symptoms of borderline personality disorder (BPD) and bipolar disorder (BD) often overlap. In some cases, it is difficult to conduct a differential diagnosis based only on current diagnostic criteria Therefore, it is important to find clinical factors with high discriminatory specificity that, used together with structured or semi-structured interviews, could help improve diagnostic practice. We propose that a clinical analysis of identity, self-concept and self-esteem may help distinguish the two disorders, when they are not co-morbid. Our review of the studies that analyse these constructs in BD and BPD, separately, points in the direction of qualitative differences between the two disorders. In BPD, there is a well-documented identity diffusion, and the self-concept appears predominantly negative; shifts in self-concept and self-esteem are often tied to interpersonal triggers. In BD, patients struggle with their identity, but narrative identity might be less compromised compared with BPD; the shifts in self-concept and self-esteem appear more linked to internal (i.e. mood and motivational) factors. We end the paper by discussing the implications for clinicians and ideas for future comparative research.

Fear of positive evaluation in borderline personality disorder

BACKGROUND

Being afraid of others' positive appraisal of oneself is called fear of positive evaluation. Fear of positive evaluation has been studied intensively in the context of social anxiety disorder (SAD). It is not known if individuals with borderline personality disorder (BPD) fear positive evaluation and which factors are associated with fear of positive evaluation in BPD.

METHODS

We applied the fear of positive evaluation scale and further self-report measures (e.g., social phobia inventory, rejection sensitivity questionnaire) to 36 patients with BPD, 29 patients with SAD and 35 healthy controls (HC).

RESULTS

A one-way ANOVA revealed that patients with BPD and patients with SAD reported significantly higher fear of positive evaluation than HC. Patients with BPD and SAD did not differ in their fear of positive evaluation. A hierarchical regression analysis revealed an association between rejection sensitivity and fear of positive evaluation in the BPD sample. However, this association disappeared when controlling for social anxiety.

CONCLUSION

Our results indicate that individuals with BPD fear positive evaluation as much as individuals with SAD do, which has implications for clinical practice. Our results further imply that social anxiety is decisive for high fear of positive evaluation in patients with SAD and patients with BPD.

When Beliefs Face Reality: An Integrative Review of Belief Updating in Mental Health and Illness

Belief updating is a relatively nascent field of research that examines how people adjust their beliefs in light of new evidence. So far, belief updating has been investigated in partly unrelated lines of research from different psychological disciplines. In this article, we aim to integrate these disparate lines of research. After presenting some prominent theoretical frameworks and experimental designs that have been used for the study of belief updating, we review how healthy people and people with mental disorders update their beliefs after receiving new information that supports or challenges their views. Available evidence suggests that both healthy people and people with particular mental disorders are prone to certain biases when updating their beliefs, although the nature of the respective biases varies considerably and depends on several factors. Anomalies in belief updating are discussed in terms of both new insights into the psychopathology of various mental disorders and societal implications, such as irreconcilable political and societal controversies due to the failure to take information into account that disconfirms one’s own view. We conclude by proposing a novel integrative model of belief updating and derive directions for future research.

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.

Attending to Eliza: rapid brain responses reflect competence attribution in virtual social feedback processing

In the age of virtual communication, the source of a message is often inferred rather than perceived, raising the question of how sender attributions affect content processing. We investigated this issue in an evaluative feedback scenario. Participants were told that an expert psychotherapist, a layperson or a randomly acting computer was going to give them online positive, neutral or negative personality feedback while high-density EEG was recorded. Sender attribution affected processing rapidly, even though the feedback was on average identical. Event-related potentials revealed a linear increase with attributed expertise beginning 150 ms after disclosure and most pronounced for N1, P2 and early posterior negativity components. P3 and late positive potential amplitudes were increased for both human senders and for emotionally significant (positive or negative) feedback. Strikingly, feedback from a putative expert prompted large P3 responses, even for inherently neutral content. Source analysis localized early enhancements due to attributed sender expertise in frontal and somatosensory regions and later responses in the posterior cingulate and extended visual and parietal areas, supporting involvement of mentalizing, embodied processing and socially motivated attention. These findings reveal how attributed sender expertise rapidly alters feedback processing in virtual interaction and have implications for virtual therapy and online communication.

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.

Understanding persistent physical symptoms: Conceptual integration of psychological expectation models and predictive processing accounts

Persistent physical symptoms (PPS) are distressing, difficult to treat, and pose a major challenge to health care providers and systems. In this article, we review two disparate bodies of literature on PPS to provide a novel integrative model of this elusive condition. First, we draw on the clinical-psychological literature on the role of expectations to suggest that people with PPS develop dysfunctional expectations about health and disease that become increasingly immune to disconfirmatory information (such as medical reassurance) through cognitive reappraisal. Second, we invoke neuroscientific predictive processing accounts and propose that the psychological process of 'cognitive immunization' against disconfirmatory evidence corresponds, at the neurobiological and computational level, to too much confidence (i.e. precision) afforded to prior predictions. This can lead to an attenuation of disconfirming sensory information so that strong priors override benign bodily signals and make people believe that something serious is wrong with the body. Combining these distinct accounts provides a unifying framework for persistent physical symptoms and shifts the focus away from their causes to the sustaining mechanisms that prevent symptoms from subsiding spontaneously. Based on this integrative model, we derive new avenues for future research and discuss implications for treating people with PPS in clinical practice.

Atypical processing of social anticipation and feedback in borderline personality disorder

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Borderline personality disorder (BPD) is characterized by interpersonal dysfunction.

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In BPD, the superior temporal sulcus is hyperactivated during social anticipation.

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In BPD, amygdala response to evaluative social feedback is also reduced.

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Amygdala suppression is induced by anterior cingulate rise during social anticipation.

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Atypical frontolimbic interactions may contribute to interpersonal dysfunction in BPD.

Background-

Borderline personality disorder (BPD) is characterized by maladaptive social functioning, and widespread negativity biases. The neural underpinnings of these impairments remain elusive. We thus tested whether BPD patients show atypical neural activity when processing social (compared to non-social) anticipation, feedback, and particularly, how they relate to each other.

Methods-

We acquired functional MRI data from 21 BPD women and 24 matched healthy controls (HCs) while they performed a task in which cues and feedbacks were either social (neutral faces for cues; happy or angry faces for positive and negative feedbacks, respectively) or non-social (dollar sign; winning or losing money for positive and negative feedbacks, respectively). This task allowed for the analysis of social anticipatory cues, performance-based feedback, and their interaction.

Results-

Compared to HCs, BPD patients expressed increased activation in the superior temporal sulcus during the processing of social cues, consistent with elevated salience associated with an upcoming social event. BPD patients also showed reduced activation in the amygdala while processing evaluative social feedback. Importantly, perigenual anterior cingulate cortex (pgACC) activity during the presentation of the social cue correlated with reduced amygdala activity during the presentation of the negative social feedback in the BPD patients.

Conclusions-

These neuroimaging results clarify how BPD patients express altered responses to different types of social stimuli (i.e. social anticipatory cues and evaluative feedback) and uncover an atypical relationship between frontolimbic regions (pgACC-amygdala) over the time span of a social interaction. These findings may help to explain why BPD patients suffer from pervasive difficulties adapting their behavior in the context of interpersonal relationships and should be considered while designing better-targeted interventions.

Belief updating in depression is not related to increased sensitivity to unexpectedly negative information

BACKGROUND

People with depression differ from healthy people in the extent to which they use novel positive information to adjust negative expectations. In this study, we examined whether the two groups also differ in updating positive expectations after receiving unexpectedly negative information.

METHODS

Examining 76 people with depressive symptoms and 81 healthy controls, we used an adapted version of a previously validated paradigm. After the initial establishment of positive performance expectations, participants worked on the TEMINT performance test, whereupon half of the participants received standardized feedback that confirmed previous positive expectations while the other half received disconfirming negative feedback. Subsequently, participants' performance expectations were assessed again. Additionally, we assessed participants' appraisal of the feedback, particularly whether they tended to disregard it.

RESULTS

Results indicated that healthy subjects had overall more positive expectations than people with depressive symptoms, but the two samples did not differ in updating their expectations: both groups changed their expectations in a negative direction after receiving negative feedback; similarly, there were no differences between the two samples after receiving confirmatory positive feedback. Both people with and without depressive symptoms were more likely to disregard the feedback received if the feedback was negative, and such a negative appraisal of the feedback was associated with smaller expectation update.

CONCLUSIONS

In combination with prior work, the current findings suggest that people with depressive symptoms do not over-sensitively react to unexpectedly negative information; rather, the main problem of depression seems to be the integration of novel positive information, as shown previously.

How to modify persisting negative expectations in major depression? An experimental study comparing three strategies to inhibit cognitive immunization against novel positive experiences

BACKGROUND

Research has shown that negative expectations in major depressive disorder (MDD) often persist despite positive disconfirming experiences. To explain this phenomenon, the concept of cognitive immunization has been introduced: that is, individuals with MDD reappraise disconfirming positive evidence in such a way that negative expectations are maintained. In this study, we examined whether it is possible to inhibit cognitive immunization to facilitate expectation update.

METHODS

We examined 113 people with MDD being treated in an inpatient psychosomatic hospital. Using a previously validated paradigm, participants worked on a standardized performance test; we examined changes in negative performance-related expectations after positive expectation-disconfirming feedback. One experimental group received additional information increasing the value of the positive feedback ('INFORMATION'). Another group was instructed to recall the feedback after completing the task ('RECALL'). In a third group, participants' attention was shifted to potential expectation-disconfirming feedback ('ATTENTION'). In addition, a control group underwent the standard procedure of the paradigm.

RESULTS

The results showed significant group differences in the change in generalized performance expectations, with the largest changes in participants from the INFORMATION group. All experimental groups had lower values for cognitive immunization than the control group.

LIMITATIONS

Given that this proof-of-concept study was the first to examine strategies to inhibit cognitive immunization, the findings need to be replicated in future studies.

CONCLUSIONS

The present study confirms that cognitive immunization in MDD can be inhibited, thus facilitating adjusting negative expectations. The most promising results were found for the INFORMATION group, providing information to emphasize the relevance of expectation-disconfirming information.

The heart trumps the head: Desirability bias in political belief revision

Understanding how individuals revise their political beliefs has important implications for society. In a preregistered study (N = 900), we experimentally separated the predictions of 2 leading theories of human belief revision—desirability bias and confirmation bias—in the context of the 2016 U.S. presidential election. Participants indicated who they desired to win, and who they believed would win, the election. Following confrontation with evidence that was either consistent or inconsistent with their desires or beliefs, they again indicated who they believed would win. We observed a robust desirability bias—individuals updated their beliefs more if the evidence was consistent (vs. inconsistent) with their desired outcome. This bias was independent of whether the evidence was consistent or inconsistent with their prior beliefs. In contrast, we found limited evidence of an independent confirmation bias in belief updating. These results have implications for the relevant psychological theories and for political belief revision in practice.

Understanding Negative Self-Evaluations in Borderline Personality Disorder-a Review of Self-Related Cognitions, Emotions, and Motives

Self-conscious emotions, such as guilt, shame, or self-disgust, as well as self-related motives, such as self-enhancement or self-verification, influence how people perceive, evaluate, memorize, and respond to self-related information. They not only influence peoples' concepts of themselves but may also affect their behavior in social environments. In the current review, we describe alterations of self-related processing in borderline personality disorder (BPD). We chose BPD as an example of a mental disorder of which impairments in self-functioning and identity constitute a major feature. Since terminology used in clinical research on self-referential processing is diverse and often confusing, we start with reviewing some of the main concepts in this area of research using a conceptual framework provided from social psychology. Most studies on self-referential processing in BPD focused on descriptions of self-esteem and revealed a negative self-concept, particularly expressed by explicitly reported low self-esteem. Moreover, self-esteem is unstable in BPD and likely reactive to self-relevant cues. BPD patients are prone to negative emotions with respect to themselves, such as self-disgust and shame. First data point to altered self-related motives, too. In conclusion, although explicit self-esteem is widely studied as a global and trait-like feature of BPD, there is a strong lack of studies that take the complexity of the construct self-esteem into account. Further studies on alterations in self-related processes are required to deepen our understanding of impairments of the self-concept in BPD and enable the improvement of psychosocial therapeutic approaches.

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.

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.

Mapping the brain correlates of borderline personality disorder: A functional neuroimaging meta-analysis of resting state studies

BACKGROUND

Altered intrinsic function of the brain has been implicated in Borderline Personality Disorder (BPD). Nonetheless, imaging studies have yielded inconsistent alterations of brain function. To investigate the neural activity at rest in BPD, we conducted a set of meta-analyses of brain imaging studies performed at rest.

METHODS

A total of seven functional imaging studies (152 patients with BPD and 147 control subjects) were combined using whole-brain Signed Differential Mapping meta-analyses. Furthermore, two conjunction meta-analyses of neural activity at rest were also performed: with neural activity changes during emotional processing, and with structural differences, respectively.

RESULTS

We found altered neural activity in the regions of the default mode network (DMN) in BPD. Within the regions of the midline core DMN, patients with BPD showed greater activity in the anterior as well as in the posterior midline hubs relative to controls. Conversely, in the regions of the dorsal DMN they showed reduced activity compared to controls in the right lateral temporal complex and bilaterally in the orbitofrontal cortex. Increased activity in the precuneus was observed both at rest and during emotional processing. Reduced neural activity at rest in lateral temporal complex was associated with smaller volume of this area.

LIMITATIONS

Heterogeneity across imaging studies.

CONCLUSIONS

Altered activity in the regions of the midline core as well as of the dorsal subsystem of the DMN may reflect difficulties with interpersonal and affective regulation in BPD. These findings suggest that changes in spontaneous neural activity could underlie core symptoms in BPD.

Self-stigma in borderline personality disorder - cross-sectional comparison with schizophrenia spectrum disorder, major depressive disorder, and anxiety disorders

INTRODUCTION

Self-stigma arises from one's acceptance of societal prejudices and is common in psychiatric patients. This investigation compares the self-stigma of a sample of patients with borderline personality disorder (BPD), schizophrenia spectrum disorder (SCH), major depressive disorder (MDD), bipolar affective disorder (BAD), and anxiety disorders (AD) and explores of the self-stigma with the subjective and objective measures of the severity of the disorder and demographic factors.

METHODS

The total of 184 inpatients admitted to the psychotherapeutic department diagnosed with BPD, SCH, MDD, BAP, and AD were compared on the internalized stigma of mental illness (ISMI) scale. The ISMI-total score was correlated with the subjective and objective evaluation of the disorder severity (clinical global impression), and clinical and demographic factors.

RESULTS

The self-stigma levels were statistically significantly different among the diagnostic groups (BPD 71.15±14.74; SCH 63.2±13.27; MDD 64.09±12.2; BAD 62.0±14.21; AD 57.62±15.85; one-way analysis of variance: F=8.698, df=183; P<0.005). However after applying the Bonferroni's multiple comparison test, the only significant difference was between the BPD patients and the patients with AD (P<0.001). Stepwise regression analysis showed that the strongest factors connected with the higher level of self-stigma were being without partner, the number of hospitalization, and the severity of the disorder.

CONCLUSION

The BPD patients suffer from a higher level of self-stigma compared to patients with AD. In practice, it is necessary to address the reduction of self-stigma by using specific treatment strategies, such as cognitive therapy.