Imagery rescripting in individuals with binge-eating behavior: An experimental proof-of-concept study.

OBJECTIVE: Mental imagery is more strongly related to emotions than verbal cognitions. Binge eating is associated with dysfunctional emotional regulation. However, cognitive therapy techniques have focused on verbal cognitions. This proof-of-concept study compares a traditional cognitive therapy technique, cognitive restructuring (CR), with imagery rescripting (IR) in individuals with binge-eating disorder or bulimia nervosa. METHOD: Thirty-six participants were asked to recall an idiosyncratic mental image of social rejection. They were then randomly assigned to a single session of CR or IR. Ratings of positive and negative emotions, and impact on rational and emotional core beliefs were administered prior to and after imagery recall, after the experimental intervention, and 1 week later. Eating disorder psychopathology was measured before and 1 week after the experimental intervention. RESULTS: Repeated measures ANOVAs revealed that after the experimental intervention, negative emotions and core beliefs had significantly decreased in CR and IR. Both groups also showed an increase in positive emotions that lasted until 1-week follow-up. DISCUSSION: This study suggests that CR and IR as an experimental intervention have comparable impact on distress and rational and emotional core beliefs. The feasibility of IR has been demonstrated. The effect of imagery recall on CR needs further investigation.

Always on guard: emotion regulation in women with borderline personality disorder compared to nonpatient controls and patients with cluster-C personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is characterized by emotion dysregulation; however, it is unclear whether this is restricted to negative emotional stimuli or to what degree this is specific to BPD. We investigated neural correlates of hypothesized increased emotional sensitivity and impaired emotion regulation in patients with BPD. METHODS: During functional MRI (fMRI) scanning, patients with BPD, nonpatient controls and patients with cluster-C personality disorder completed an emotion regulation task, including negative, positive and erotic social pictures. RESULTS: We included 55 patients with BPD, 42 nonpatient controls and 24 patients with cluster-C personality disorder in our analyses. Passive viewing of negative stimuli resulted in greater activity in the anterior insula, temporoparietal junction and dorsolateral prefrontal cortex in patients with BPD than in nonpatient controls. The increased activity in the anterior insula and temporoparietal junction was also present when patients with BPD viewed positive stimuli. During regulation of negative stimuli compared with passive viewing, nonpatient controls showed greater activity in the dorsal anterior cingulate cortex, dorsolateral prefrontal cortex, middle temporal gyrus and bilateral inferior parietal lobule. Patients with BPD did not show this increase in activity. LIMITATIONS: Findings cannot be generalized to men, and patients represented a heterogeneous group regarding comorbid diagnoses and medication. CONCLUSION: When looking at emotional stimuli, patients with BPD showed a unique pattern of activity, suggesting an increase in brain activity involved in emotion generation. In the case of negative stimuli this is accompanied by increased activity in regulation areas. In contrast, increase of regulation processes seems absent when patients with BPD are explicitly instructed to regulate. Results of diagnosis specificity support a dimensional rather than a dichotomous differentiation between BPD and cluster-C personality disorder regarding emotional sensitivity and emotional regulation of social stimuli.

Always on guard: emotion regulation in women with borderline personality disorder compared to nonpatient controls and patients with cluster-C personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is characterized by emotion dysregulation; however, it is unclear whether this is restricted to negative emotional stimuli or to what degree this is specific to BPD. We investigated neural correlates of hypothesized increased emotional sensitivity and impaired emotion regulation in patients with BPD. METHODS: During fMRI scanning, patients with BPD, nonpatient controls and patients with cluster-C personality disorder completed an emotion regulation task, including negative, positive and erotic social pictures. RESULTS: We included 55 patients with BPD, 42 nonpatient controls and 24 patients with cluster-C personality disorder in our analyses. Passive viewing of negative stimuli resulted in greater activity in the anterior insula, temporoparietal junction and dorsolateral prefrontal cortex in patients with BPD than in nonpatient controls. The increased activity in the anterior insula and temporoparietal junction was also present when patients with BPD viewed positive stimuli. During regulation of negative stimuli compared with passive viewing, nonpatient controls showed greater activity in the dorsal anterior cingulate cortex, dorsolateral prefrontal cortex, middle temporal gyrus and bilateral inferior parietal lobule. Patients with BPD did not show this increase in activity. LIMITATIONS: Findings cannot be generalized to men, and patients represented a heterogeneous group regarding comorbid diagnoses and medication. CONCLUSION: When looking at emotional stimuli, patients with BPD showed a unique pattern of activity, suggesting an increase in brain activity involved in emotion generation. In the case of negative stimuli this is accompanied by increased activity in regulation areas. In contrast, increase of regulation processes seems absent when patients with BPD are explicitly instructed to regulate. Results of diagnosis specificity support a dimensional rather than a dichotomous differentiation between BPD and cluster-C personality disorder regarding emotional sensitivity and emotional regulation of social stimuli.

Deficient amygdala-prefrontal intrinsic connectivity after effortful emotion regulation in borderline personality disorder.

Emotion instability in borderline personality disorder (BPD) has been associated with an impaired fronto-limbic inhibitory network. However, functional connectivity (FC) underlying altered emotion regulation in BPD has yet to be established. Here, we used resting-state fMRI to investigate enduring effects of effortful emotion regulation on the amygdala intrinsic FC in BPD. In this multicenter study, resting-state fMRI was acquired before and after an emotion regulation task in 48 BPD patients and 39 non-patient comparison individuals. The bilateral amygdalae were used as a seed in the whole-brain FC analysis and two-way mixed ANOVA to test whether BPD patients exhibited weaker post-task increase in the amygdala intrinsic FC with the prefrontal cortex (PFC), compared to non-patients. Subsequently, we explored whether the results are common for personality disorders characterized by emotional problems, using additional data of 21 cluster-C personality disorder patients. In contrast to non-patients, BPD patients failed to show increased post-task amygdala resting-state FC with the medial, dorsolateral, ventrolateral PFC, and superior temporal gyrus, but surprisingly exhibited decreased FC with the posterior cingulate cortex and increased FC with the superior parietal lobule. In BPD patients, the emotion regulation task failed to increase resting-state amygdala FC with brain regions essential for effortful emotion regulation, which suggests: (a) altered cognitive control typically used to indirectly alleviate distress by reinterpreting the meaning of emotional stimuli; (b) impaired direct regulation of emotional responses, which might be common for personality disorders;

Attentional Bias for Emotional Stimuli in Borderline Personality Disorder: A Meta-Analysis.

BACKGROUND: In borderline personality disorder (BPD), attentional bias (AB) to emotional stimuli may be a core component in disorder pathogenesis and maintenance. SAMPLING: 11 emotional Stroop task (EST) studies with 244 BPD patients, 255 nonpatients (NPs) and 95 clinical controls and 4 visual dot-probe task (VDPT) studies with 151 BPD patients or subjects with BPD features and 62 NPs were included. METHODS: We conducted two separate meta-analyses for AB in BPD. One meta-analysis focused on the EST for generally negative and BPD-specific/personally relevant negative words. The other meta-analysis concentrated on the VDPT for negative and positive facial stimuli. RESULTS: There is evidence for an AB towards generally negative emotional words compared to NPs (standardized mean difference, SMD = 0.311) and to other psychiatric disorders (SMD = 0.374) in the EST studies. Regarding BPD-specific/personally relevant negative words, BPD patients reveal an even stronger AB than NPs (SMD = 0.454). The VDPT studies indicate a tendency towards an AB to positive facial stimuli but not negative stimuli in BPD patients compared to NPs. CONCLUSIONS: The findings rather reflect an AB in BPD to generally negative and BPD-specific/personally relevant negative words rather than an AB in BPD towards facial stimuli, and/or a biased allocation of covert attentional resources to negative emotional stimuli in BPD and not a bias in focus of visual attention. Further research regarding the role of childhood traumatization and comorbid anxiety disorders may improve the understanding of these underlying processes.

Integration of e-Health Tools Into Face-to-Face Psychotherapy for Borderline Personality Disorder: A Chance to Close the Gap Between Demand and Supply?

Borderline personality disorder (BPD) is a severe, highly prevalent mental disorder. Effective psychological treatments for BPD are available. However, most patients do not receive evidence-based treatments partly because of high treatment delivery costs and lack of specialized therapists. By integrating specialized e-health tools into BPD-specific treatments, treatment intensity can be increased, frequency of face-to-face sessions and burden for psychotherapists can be reduced, and implementation of new skills and experiences in the everyday life of these patients can be promoted. This bears great potential to increase the availability of evidenced-based psychotherapy for BPD patients and close the gap between demand and supply. In this article we present such an innovative e-health tool, priovi, which has been developed for schema therapy. The concept and application of priovi are described and illustrated with a case example.

Associations between Grawe's general mechanisms of change and Young's early maladaptive schemas in psychotherapy research: a comparative study of change processes.

OBJECTIVE: The study aimed at analyzing associations between Grawe's general mechanisms of change and Young's early maladaptive schemas (EMS). METHOD: Therefore, 98 patients completed the Scale for the Multiperspective Assessment of General Change Mechanisms in Psychotherapy (SACiP), the Young Shema Questionnaire-Short Form Revised (YSQ S3R), and diverse outcome measures at the beginning and end of treatment. RESULTS: Our results are important for clinical applications, as we demonstrated strong predictive effects of change mechanisms on schema domains using regression analyses and cross-lagged panel models. CONCLUSIONS: Resource activation experiences seem to be especially crucial in fostering alterations in EMS, as this change mechanism demonstrated significant associations with several schema domains. Future research should investigate these aspects in more detail using observer-based micro-process analyses.

Design of an international multicentre RCT on group schema therapy for borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is a severe and highly prevalent mental disorder. Schema therapy (ST) has been found effective in the treatment of BPD and is commonly delivered through an individual format. A group format (group schema therapy, GST) has also been developed. GST has been found to speed up and amplify the treatment effects found for individual ST. Delivery in a group format may lead to improved cost-effectiveness. An important question is how GST compares to treatment as usual (TAU) and what format for delivery of schema therapy (format A; intensive group therapy only, or format B; a combination of group and individual therapy) produces the best outcomes. METHODS/DESIGN: An international, multicentre randomized controlled trial (RCT) will be conducted with a minimum of fourteen participating centres. Each centre will recruit multiple cohorts of at least sixteen patients. GST formats as well as the orders in which they are delivered to successive cohorts will be balanced. Within countries that contribute an uneven number of sites, the orders of GST formats will be balanced within a difference of one. The RCT is designed to include a minimum of 448 patients with BPD. The primary clinical outcome measure will be BPD severity. Secondary clinical outcome measures will include measures of BPD and general psychiatric symptoms, schemas and schema modes, social functioning and quality of life. Furthermore, an economic evaluation that consists of cost-effectiveness and cost-utility analyses will be performed using a societal perspective. Lastly, additional investigations will be carried out that include an assessment of the integrity of GST, a qualitative study on patients' and therapists' experiences with GST, and studies on variables that might influence the effectiveness of GST. DISCUSSION: This trial will compare GST to TAU for patients with BPD as well as two different formats for the delivery of GST. By combining an evaluation of clinical effectiveness, an economic evaluation and additional investigations, it will contribute to an evidence-based understanding of which treatment should be offered to patients with BPD from clinical, economic, and stakeholders' perspectives. TRIAL REGISTRATION: Netherlands Trial Register NTR2392. Registered 25 June 2010.

Beyond words: sensory properties of depressive thoughts.

Verbal thoughts (such as negative cognitions) and sensory phenomena (such as visual mental imagery) are usually conceptualised as distinct mental experiences. The present study examined to what extent depressive thoughts are accompanied by sensory experiences and how this is associated with symptom severity, insight of illness and quality of life. A large sample of mildly to moderately depressed patients (N = 356) was recruited from multiple sources and asked about sensory properties of their depressive thoughts in an online study. Diagnostic status and symptom severity were established over a telephone interview with trained raters. Sensory properties of negative thoughts were reported by 56.5% of the sample (i.e., sensation in at least one sensory modality). The highest prevalence was seen for bodily (39.6%) followed by auditory (30.6%) and visual (27.2%) sensations. Patients reporting sensory properties of thoughts showed more severe psychopathological symptoms than those who did not. The degree of perceptuality was marginally associated with quality of life. The findings support the notion that depressive thoughts are not only verbal but commonly accompanied by sensory experiences. The perceptuality of depressive thoughts and the resulting sense of authenticity may contribute to the emotional impact and pervasiveness of such thoughts, making them difficult to dismiss for their holder.

Emotional modulation of motor response inhibition in women with borderline personality disorder: an fMRI study.

BACKGROUND: Both emotion regulation and impulsivity are core aspects of borderline personality disorder (BPD) pathology. Although both problems may be combined specifically in BPD, few studies to date have investigated the emotional modulation of impulsivity in BPD. METHODS: Women with BPD and matched healthy controls performed go/no-go tasks after induction of anger, joy or a neutral mood by vocally presented short stories. Dependent variables were the behavioural results and functional magnetic resonance imaging data. RESULTS: We included 17 women with BPD and 18 controls in our study. No behavioural group differences were found. However, patients with BPD showed stronger activation of the left amygdala and weaker activation of the subgenual anterior cingulate during anger induction than controls. Inhibition in the go/no-go task after anger induction increased activity in the left inferior frontal cortex in controls, but not in women with BPD, who, in turn, showed increased activation in the subthalamic nucleus. LIMITATIONS: Findings cannot be generalized to men, and 4 patients were taking antidepressant medication (selective serotonin reuptake inhibitors). In addition, no patient control group was investigated, thus we do not know whether findings are specific to BPD compared with other disorders. CONCLUSION: Our findings are consistent with the view that a disturbed amygdala-prefrontal network in patients with BPD is compensated by a subcortical loop involving the subthalamic nucleus, leading to normal behavioural inhibition in these patients.

Effectiveness of Predominantly Group Schema Therapy and Combined Individual and Group Schema Therapy for Borderline Personality Disorder: A Randomized Clinical Trial.

IMPORTANCE: Schema therapy (ST), delivered either in an individual or group format, has been compared with other active treatments for borderline personality disorder (BPD). To our knowledge, the 2 formats have not been compared with treatment as usual (TAU) or with each other. Such comparisons help determine best treatment practices. OBJECTIVE: To evaluate whether ST is more effectively delivered in a predominantly group or combined individual and group format and whether ST is more effective than optimal TAU for BPD. DESIGN, SETTING, AND PARTICIPANTS: In this multicenter, 3-arm randomized clinical trial conducted at 15 sites in 5 countries (Australia, Germany, Greece, the Netherlands, and the UK), outpatients aged 18 to 65 years who had BPD were recruited between June 29, 2010, and May 18, 2016, to receive either predominantly group ST (PGST), combined individual and group ST (IGST), or optimal TAU. Data were analyzed from June 4, 2019, to December 29, 2021. INTERVENTIONS: At each site, cohorts of 16 to 18 participants were randomized 1:1 to PGST vs TAU or IGST vs TAU. Both ST formats were delivered over 2 years, with 2 sessions per week in year 1 and the frequency gradually decreasing during year 2. Assessments were collected by blinded assessors. MAIN OUTCOMES AND MEASURES: The primary outcome was the change in BPD severity over time, assessed with the Borderline Personality Disorder Severity Index (BPDSI) total score. Treatment retention was analyzed as a secondary outcome using generalized linear mixed model survival analysis. RESULTS: Of 495 participants (mean [SD] age, 33.6 [9.4] years; 426 [86.2%] female), 246 (49.7%) received TAU, 125 (25.2%) received PGST, and 124 (25.0%) received IGST (1 of whom later withdrew consent). PGST and IGST combined were superior to TAU with regard to reduced BPD severity (Cohen d, 0.73; 95% CI, 0.29-1.18; P < .001). For this outcome, IGST was superior to TAU (Cohen d, 1.14; 95% CI, 0.57-1.71; P < .001) and PGST (Cohen d, 0.84; 95% CI, 0.09-1.59; P = .03), whereas PGST did not differ significantly from TAU (Cohen d, 0.30; 95% CI, -0.29 to 0.89; P = .32). Treatment retention was greater in the IGST arm than in the PGST (1 year: 0.82 vs 0.72; 2 years: 0.74 vs. 0.62) and TAU (1 year: 0.82 vs 0.73; 2 years: 0.74 vs 0.64) arms, and there was no significant difference between the TAU and PGST arms (1 year: 0.73 vs 0.72; 2 years: 0.64 vs 0.62). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, IGST was more effective and had greater treatment retention compared with TAU and PGST. These findings suggest that IGST is the preferred ST format, with high retention and continuation of improvement in BPD severity after the completion of treatment. TRIAL REGISTRATION: trialregister.nl Identifier: NTR2392.

Looking at the bigger picture: Cortical volume, thickness and surface area characteristics in borderline personality disorder with and without posttraumatic stress disorder.

Borderline personality disorder (BPD) is a severe psychiatric disorder accompanied by multiple comorbidities. Neuroimaging studies have identified structural abnormalities in BPD with most findings pointing to gray matter volume reductions in the fronto-limbic network, although results remain inconsistent. Similar alterations were found in posttraumatic stress disorder (PTSD), a common comorbidity of BPD. Only a small number of studies have investigated structural differences in BPD patients regarding comorbid PTSD specifically and studies conducting additional surface analyses are scarce. We investigated structural differences in women with BPD with and without PTSD and non-patient controls. Automated voxel-based and region-based volumetric analyses were applied. Additionally, four surface-based measures were analyzed: cortical thickness, gyrification index, fractal dimension, and sulcus depth. Analyses did not identify cortical volume alterations in the fronto-limbic network. Instead, hypergyrification was detected in the right superior parietal cortex in BPD patients compared to non-patient controls. No distinction was revealed between BPD patients with and without PTSD. These findings underline the importance of a holistic investigation examining volumetric and surface measures as these might enhance the understanding of structural alterations in BPD.

Impulsivity in borderline personality disorder: impairment in self-report measures, but not behavioral inhibition.

BACKGROUND: Impulsivity is a core feature of borderline personality disorder (BPD). However, previous clinical and experimental studies investigating impulsivity in BPD rendered mixed results. In this study, impulsivity was assessed by self-report scales and behavioral inhibition tasks to compare different data levels. SAMPLING AND METHODS: Fifteen women with BPD and 15 matched healthy control subjects (HC) completed the Barratt Impulsiveness Scale, Eysenck's Impulsivity Questionnaire and the UPPS (Urgency, Lack of Perseverance, Lack of Premeditation and Sensation Seeking) scale, and participated in a Stroop task, an antisaccade task and a stop signal task. RESULTS: Patients with BPD scored significantly higher on self-report measures as compared to HC, but not in behavioral tests. In BPD patients, but not in HC, behavioral inhibition errors were correlated with more intense emotional state. CONCLUSION: We found a discrepancy between self-report and behavioral data. Further studies need to assess additional possible mechanisms underlying increased impulsivity, their relation to emotional instability, and their neurobiological underpinnings.

Patients with borderline personality disorder and comorbid PTSD show biased attention for threat in the facial dot-probe task.

BACKGROUND AND OBJECTIVES: Biased attention to threat is likely to play a crucial role in the dysfunctional emotion-related information processing in borderline personality disorder (BPD). However, the role of comorbid posttraumatic stress disorder (PTSD) has not yet been fully disentangled. METHODS: BPD patients with (n = 24) and without (n = 46) PTSD, 35 patients with Cluster-C personality disorder and 52 non-patients participated in the facial dot-probe task with angry, happy and neutral faces during automatic (100 ms), controlled (600 ms), and later (1200 ms) stages of information processing. RESULTS: BPD patients showed a greater congruency effect to angry faces during the controlled stage of processing than controls. Specifically, in BPD with PTSD compared to controls, this effect was due to difficulties disengaging from threat, indicated by slower reaction times to incongruent angry targets compared to neutral trials. Regarding automatic and later stages of information processing, there was no attentional bias (AB) in BPD. None of the groups revealed biased attention for happy faces at any stages of information processing. LIMITATIONS: We did not include a control group of PTSD patients without BPD. Therefore, we cannot rule out that the present AB in BPD is mainly due to PTSD-specific psychopathology. CONCLUSIONS: These findings provide first evidence for an AB towards angry faces and difficulties disengaging from these threat-related social cues in adult BPD patients. Although BPD patients in general demonstrated an AB when compared with controls, this effect was especially pronounced for BPD with PTSD, suggesting a significant effect of trauma-related psychopathology on social attention in BPD.

Impulse control under emotion processing: an fMRI investigation in borderline personality disorder compared to non-patients and cluster-C personality disorder patients.

Impulsivity is a characteristic syndromal and neurobehavioral feature of borderline personality disorder (BPD). Research suggests an important interaction between high negative emotions and low behavioral inhibition in BPD. However, knowledge about the generalizability across stimulus categories and diagnosis specificity is limited. We investigated neural correlates of hypothesized impaired response inhibition of BPD patients to negative, positive and erotic stimuli, by comparing them to non-patients and cluster-C personality disorder patients. During fMRI scanning, 53 BPD patients, 34 non-patients and 20 cluster-C personality disorder patients completed an affective go/no-go task, including social pictures. BPD patients showed more omission errors than non-patients, independent of the stimulus category. Furthermore, BPD patients showed higher activity in the inferior parietal lobule and frontal eye fields when inhibiting negative versus neutral stimuli. Activity of the inferior parietal lobule correlated positively with the BPD checklist subscale impulsivity. When inhibiting emotional stimuli, BPD patients showed an altered brain activity in the inferior parietal lobe and frontal eye fields, whereas previously shown dysfunctional prefrontal activity was not replicated. BPD patients showed a general responsivity across stimulus categories in the frontal eye fields, whereas effects in the inferior parietal lobe were specific for negative stimuli. Results of diagnosis specificity support a dimensional rather than a categorical differentiation between BPD and cluster-C patients during inhibition of social emotional stimuli. Supported by behavioral results, BPD patients showed no deficiencies in emotionally modulated response inhibition per se but the present findings rather hint at attentional difficulties for emotional information.

Therapeutic Relationship in eHealth-A Pilot Study of Similarities and Differences between the Online Program Priovi and Therapists Treating Borderline Personality Disorder.

eHealth programs have been found to be effective in treating many psychological conditions. Regarding Borderline Personality Disorder (BPD), few programs have been tested; nevertheless, results are promising. The therapeutic alliance is an important factor predicting treatment outcome in BPD. However, we do not know yet to what extent BPD patients form a therapeutic alliance with an eHealth tool and how this relationship differs from the relationship with their human therapist. This study aims to address this question using priovi, an interactive schema therapy-based eHealth tool for BPD. Semi-structured interviews were conducted to explore how patients perceived the therapeutic alliance with priovi and its differences compared to the alliance with their human therapist (N = 9). Interview data were analyzed following the procedures of qualitative content analysis. Additionally, the Working Alliance Inventory (WAI-SR) was administered in two versions (regarding the human therapist and priovi, N = 16) every three months during the treatment phase of one year. Results indicate that patients were able to form a good therapeutic relationship with priovi, but it differed from the relationship to their human therapist. Important categories were "priovi is helpful, supportive and always there" and "priovi is less flexible". WAI ratings for the task subscale were high in both relationships but significantly higher in WAItherapist compared to WAIpriovi in two measurements (nine-months measurement: t = 2.76, df = 15, p = 0.015; twelve-months measurement: t = 3.44, df = 15, p = 0.004). These results indicate that BPD patients can form a functioning alliance with an eHealth program and that eHealth programs may be especially useful for psychoeducation and cognitive exercises.

Emotional reactions to standardized stimuli in women with borderline personality disorder: stronger negative affect, but no differences in reactivity.

Emotional dysregulation is hypothesized to be a core feature of borderline personality disorder (BPD). In this study, we investigated the course of emotions in response to standardized emotion inductions in BPD. A total of 26 female BPD patients, 28 matched healthy control subjects, and 15 female patients with major depressive disorder listened to short stories inducing an angry, joyful, or neutral mood. Before and immediately after each story as well as 3 and 6 minutes later, participants rated their current anger, joy, anxiety, shame, and sadness. All 3 groups showed the same increase and decrease of emotions. However, strong group differences in the general level of all negative emotions occurred. While sadness was stronger both in BPD and major depressive disorder as compared with healthy controls, all other negative emotions were significantly increased in BPD only independent of comorbid depression. Extreme negative affectivity may be a more appropriate description of BPD-related emotional problems than emotional hyperreactivity.

Biased Attention to Facial Expressions of Ambiguous Emotions in Borderline Personality Disorder: An Eye-Tracking Study.

Preliminary evidence suggests that biased attention could be crucial in fostering the emotion recognition abnormalities in borderline personality disorder (BPD). We compared BPD patients to Cluster-C personality disorder (CC) patients and non-patients (NP) regarding emotion recognition in ambiguous faces and their visual attention allocation to the eyes. The role of comorbid posttraumatic stress disorder (PTSD) in BPD regarding emotion recognition and visual attention was explored. BPD patients fixated the eyes of angry/happy, sad/happy, and fearful/sad blends longer than non-patients. This visual attention pattern was mainly driven by BPD patients with PTSD. This subgroup also demonstrated longer fixations than CC patients and a trend towards longer fixations than BPD patients without PTSD for the angry/happy and fearful/sad blends. Emotion recognition was not altered in BPD. Biased visual attention towards the eyes of ambiguous facial expressions in BPD might be due to trauma-related attentional bias rather than to impairments in facial emotion recognition.