Body self-evaluation and physical scars in patients with borderline personality disorder: an observational study

Self-Reported Stress, Trauma, and Prevalence of Laryngoresponders in the General Population

INTRODUCTION

It has been proposed that some individuals are "laryngoresponders" (LRs) in that their stress manifests in the laryngeal region and laryngeal functions (e.g., voice and breathing). Preliminary data support the notion that LRs might differ from nonlaryngoresponders (NLRs) in their self-reported past trauma and recent stress. The purpose of this study was to establish the point prevalence of self-identified LRs in the general population.

METHOD

Using a web-based questionnaire, participants reported up to 13 stress-vulnerable bodily regions and described symptom nature and severity for each region. At the end of the questionnaire, they were explicitly prompted to report whether their laryngeal region or its functions were affected by stress. Participants were categorized a posteriori as Unprompted LRs, Prompted LRs, Inconsistent LRs, or NLRs. We compared LR and NLR groups on the Perceived Stress Scale (PSS-10) and the Childhood Trauma Questionnaire (CTQ-SF). We also redistributed the survey to a subset of participants to establish grouping reliability.

RESULTS

A total of 1,217 adults responded to the survey, and 995 provided complete data sets. Of those, 15.7% were classified as Unprompted LRs, 26.7% as Prompted LRs, 3% as Inconsistent LRs, and 54.6% as NLRs. Unprompted LRs demonstrated significantly higher/worse PSS-10 and CTQ-SF scores than all other groups. Reliability of LR classification was moderate upon follow-up, κ = .62, 95% confidence interval [0.47, 0.77].

CONCLUSIONS

Unprompted LRs described their symptoms in ways that were indistinguishable from patients with functional voice disorders (e.g., throat clenches, voice gets tired easily, lose my voice, voice gets hoarse). The method of self-report solicitation impacted the resulting response. Specifically, the report of larynx-related symptoms differed substantially depending on whether or not the participants were directly prompted to consider the larynx and its related functions.

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

Background

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

Methods

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

Results

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

Conclusion

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

Is Childhood Maltreatment Associated with Body Image Disturbances in Adulthood? A Systematic Review and Meta-Analysis

PURPOSE

We aimed to synthesize the evidence for an association between childhood maltreatment and body image disturbances in adulthood. Information on maltreatment subtypes and mediator variables was included to gain further insights into the mechanisms of the association. In addition, we aimed to examine the role of body image disturbances in the development of negative mental health outcomes associated with childhood maltreatment.

METHODS

Based on a comprehensive search strategy, eligible studies were identified in PubMed, Scopus, and Web of Science. The eligibility assessment was performed by two reviewers, and 132 articles were studied full-text. To reduce heterogeneity, only non-clinical samples were included in the meta-analysis. A meta-regression was computed to examine the influence of maltreatment subtype on body image disturbances.

RESULTS

Our results provide evidence for a robust association between childhood maltreatment and cognitive-affective body image, both in clinical and community samples. Included studies (N = 40) indicate that body image disturbances are especially pronounced in individuals suffering from Posttraumatic Stress Disorder (PTSD) after childhood maltreatment. The meta-analysis included 12 studies with a total of 15.481 participants, and indicates a small overall effect size (r = 0.21, 95% CI = [0.16, 0.26], p < .001). Meta-regression revealed no significant impact of maltreatment subtype in non-clinical samples.

CONCLUSION

Childhood maltreatment should be considered as a distal risk factor for the development of a negative cognitive-affective body image. We argue for future longitudinal studies which allow a better understanding of the pathways linking childhood maltreatment, body image disturbances and associated psychopathology.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40653-021-00379-5.

Body Image in Borderline Personality Disorder: A Systematic Review of the Emerging Empirical Literature

As an element of distorted self-image, body image disturbances may be relevant to borderline personality disorder (BPD). Therefore, this systematic review aims to critically discuss and summarize empirical findings in this matter. Based on the available theoretical models, three body image components were identified: (a) perception, (b) affect and cognition, and (c) general body dissatisfaction. We conducted a systematic search of the empirical literature published in English in the MEDLINE, PsycINFO, and Scopus databases until June 2021 using a priori eligibility criteria (BPD; BPD symptoms or features in nonclinical groups; quasipsychotic or psychotic symptoms were not considered). We included k = 10 records meeting the criteria. Compared with other analyzed groups, individuals diagnosed with BPD obtained higher scores in the three components of body image disturbances. The issue of body image in BPD is relatively understudied, although current research findings clearly indicate disturbances in all of the abovementioned body image components in individuals with BPD or significant relationships of these components with BPD traits or symptoms both in clinical and nonclinical samples. Eventually, possible practical implications and future research directions are also discussed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Reductions in Whole-body Ownership in Borderline Personality Disorder - A Phenomenological Manifestation of Dissociation

Body ownership, i.e., the certainty that own body parts belongs to oneself, is a fundamental feature of self-consciousness. Patients with borderline personality disorder (BPD) often show symptoms of dissociation, describing a state of detachment from reality including their own body. However, up to now, there is no study that a) quantifies body ownership experiences in BPD, b) compares these experiences between the current and the remitted state of the disorder, and c) relates this kind of experience specifically to dissociation. In the present study, we assessed ownership for 25 body areas in current BPD patients (cBPD) and compared their ratings with those of remitted BPD patients (rBPD) and healthy controls (HC). We further related body ownership to dissociation and other relevant BPD markers on body area and subject level by applying multi-level analyses in the cBPD group. We found significantly reduced body ownership experiences in cBPD compared to HC, while there were no significant differences between these groups and rBPD. In cBPD, reduced body ownership was significantly related to dissociation when controlled for other BPD core features. Reduced body ownership might thus constitute a relevant marker for dissociation in current BPD which could further represent a target for therapeutic approaches.

The Senses of Agency and Ownership in Patients With Borderline Personality Disorder

Patients with borderline personality disorder (BPD) not only experience a strong instability in their affect and interpersonal relations but also disturbances in their self-experience, including dissociation and body-alienation symptoms. It is not yet understood whether an altered sense of ownership (SoO) or sense of agency (SoA) may contribute to these disturbances. One recent hypothesis is that patients with BPD have a reduced sense of self and are therefore more likely to misattribute external objects or actions to their own self than healthy individuals. The present study followed up this hypothesis by investigating whether BPD patients have a more flexible body representation than healthy participants. More specifically, the active rubber hand illusion (aRHI) was applied to 21 patients with BPD and the same number of healthy participants. Using established subjective, electrodermal, and behavioral measures, the participants' SoO and SoA were assessed during the aRHI. The findings show self-reported evidence for higher SoO under anatomical hand congruency as compared to anatomical incongruency, but no evidence for group differences between BPD patients and healthy participants. This finding is inconsistent with previous findings of an enhanced SoO-related body plasticity in BPD patients. Regarding SoA, the findings show self-report evidence of higher SoA in BPD patients versus healthy participants, although this group difference was not evident in the implicit SoA measure (intentional binding). In summary, the present study only reveals partial evidence for a higher body plasticity in BPD patients. Instead, the observed variability in results appears better explainable by some generally elevated perceptual suggestibility of BPD individuals.

A proposed severity classification of borderline symptoms using the borderline symptom list (BSL-23)

BACKGROUND

The Borderline Symptom List (BSL-23) is a well-established self-rating instrument to assess the severity of borderline typical psychopathology. However, a classification of severity levels for the BSL-23 is missing.

METHODS

Data from 1.090 adults were used to develop a severity classification for the Borderline Symptom List (BSL-23). The severity grading was based on the distribution of the BSL-23 in 241 individuals with a diagnosis of BPD. Data from three independent samples were used to validate the previously defined severity grades.These validation samples included a group of treatment seeking patients with a diagnosis of BPD (n = 317), a sample of individuals with mental illnesses other than BPD (n = 176), and a healthy control sample (n = 356). The severity grades were validated from comparisons with established assessment instruments such as the International Personality Disorders Examination, the Structured Clinical Interview for DSM-IV, the global severity index of the Symptom Checklist (GSI, SCL-90), the Global Assessment of Functioning (GAF), and the Beck Depression Inventory (BDI-II).

RESULTS

Six grades of symptom severity were defined for the BSL-23 mean score: none or low: 0-0.3; mild: 0.3-0.7; moderate: 0.7-1.7; high: 1.7-2.7; very high: 2.7-3.5; and extremely high: 3.5-4. These grades received consistent empirical support from the independent instruments and samples. For instance, individuals with a severity grade of none or low were virtually free from diagnostic BPD-criteria, had a GSI below the normative population, and a high level of global functioning corresponding to few or no symptoms. Severity grades indicating high to extremely high levels of BPD symptoms were observed at a much higher rate in treatment-seeking patients (70.0%) than in clinical controls (17.6%) and healthy controls (0.0%). The BSL-23 score that best separated treatment-seeking BPD patients and clinical controls was 1.50, whereas the clearest discrimination of BPD patients and healthy controls was found at a score of 0.64.

CONCLUSIONS

The grades of BPD-specific symptom severity derived from the distribution of the BSL-23 scores received consistent empirical validation from established assessments for psychopathology. Future studies should expand this validation by including additional instruments e.g., to assess self-esteem, loneliness, connectedness, and quality of life.

Body plasticity in borderline personality disorder: A link to dissociation

INTRODUCTION

Patients with borderline personality disorder (BPD) often report an unstable sense of self, which is further enhanced in dissociative states. As one consequence, BPD patients show a labile body percept, which might result in a higher degree of body plasticity. However, experimental data on body plasticity in BPD are not yet available.

MATERIALS AND METHODS

The rubber hand illusion (RHI) probes the plasticity of one's body by inducing the feeling of ownership for an artificial limb. We tested the proneness to perceive the RHI in female patients with current and remitted BPD compared to healthy controls, and related their perceptions to state and trait dissociation.

RESULTS

Participants with current BPD, compared to healthy controls, reported higher proneness to perceive the RHI (p<.05, with an effect size [Cohen's d] of 0.68). Remission was associated with a stabilization of perceptions. RHI vividness was positively related to state and trait dissociation across the groups, and specifically in current BPD when controlling for symptom severity (all Pearson's r≥.30, p<.05).

DISCUSSION

These results indicate enhanced body plasticity related to dissociation in BPD, point to shared neurobiological mechanisms, and might help to elucidate the body-related perceptual disturbances associated with BPD.

CONCLUSION

The results provide initial empirical evidence for significant alterations in body ownership processing associated with a current BPD diagnosis, resulting in enhanced body plasticity. Dissociation significantly correlated with illusory limb ownership experiences, making body plasticity a marker for BPD.

The Physical Results of Nonsuicidal Self-Injury: The Meaning Behind the Scars

The psychological meaning of scars from nonsuicidal self-injury (NSSI) has been examined in case studies, but descriptive studies are needed to better understand the meaning of NSSI scars. College students with NSSI scars (n = 49) completed questionnaires concerning the interpretive meaning of their scars, emotions associated with their scars, and clinical symptoms. Levels of scar-related growth were positively correlated with interpersonal functions of NSSI (e.g., autonomy, self-care) and negatively correlated with likelihood of future self-injury, self-disgust, self-injury regret, and self-injury scar regret. Conversely, higher levels of scar-related shame were associated with higher likelihood of future self-injury, depressive and borderline personality disorder symptoms, self-disgust, NSSI scar-related regret, and intrapersonal functions of NSSI (e.g., marking distress, self-punishment). Individuals finding shame or guilt may be a more clinically severe group than those finding growth from their scars.

Can't stand the look in the mirror? Self-awareness avoidance in borderline personality disorder

BACKGROUND

Patients with Borderline Personality Disorder (BPD) expect and perceive social rejection stronger than healthy individuals. Shifting ones attention from oneself to others has been suggested as a mechanism to deal with the experience of social rejection. Here, we investigated whether BPD participants avoid increased self-awareness and whether this is done intentionally.

METHODS

Thirty BPD patients and 30 healthy control participants, all naïve of the study's purpose, were asked to choose either a seat facing a mirror (self-awareness) or not facing the mirror (avoidance of self-awareness). Afterwards they were asked to indicate if they have chosen the seat intentionally.

RESULTS

BPD patients avoided as a trend the chair facing the mirror more often than healthy control participants. 90 % of the patients reported that they made their seating decision intentionally in contrast to 26.7 % of the healthy participants (odd ratio = 24.75).

CONCLUSIONS

Results revealed altered reactions to self-awareness cues in BPD. While BPD patients avoided such a cue slightly more often, they were more often aware of their behavior than healthy participants. As possible explanations, a negative body related, shame-prone self-concept as well as a simultaneously increased degree of self-focused attention are suggested.

Body-Related Emotions in Posttraumatic Stress Disorder Following Childhood Sexual Abuse

Traumatic experiences are associated with emotions such as anxiety, shame, guilt, disgust, and anger. For patients who have experienced child sexual abuse, these emotions might be triggered by perceptions of their own body. The aim of this study was to investigate the extent of the association of the body to traumatic experiences and to discern the emotions linked to trauma-associated body areas. Ninety-seven female participants were assigned to four groups: post-traumatic stress disorder following child sexual abuse with co-occurring borderline personality disorder, post-traumatic stress disorder following child sexual abuse without co-occurring borderline personality disorder, borderline personality disorder without post-traumatic stress disorder, and healthy controls. Participants rated 26 body areas regarding their association with trauma and 7 emotions. Emotions were assessed by questionnaires. Results suggest that specific areas of the body are associated with trauma and linked to highly aversive emotions. In post-traumatic stress disorder patients, the areas associated with highly negative emotions were the pubic region and inner thighs. Thus, the patient's body may act as a trigger for traumatic memories.