Atypical Neural Plasticity and Behavioral Effects of Trustworthiness Learning in Borderline Personality Disorder Features.

This study distinguishes interpersonal trust learning with a novel trust learning paradigm in participants high (H-BPD) and low (L-BPD) in BPD features. Neutral faces were paired with trust-relevant behaviors in four conditions: trustworthy, untrustworthy, ambiguously trustworthy, and mixed trustworthiness. After training, participants rated faces on untrustworthiness as electroencephalographic measures were recorded. H-BPD rated neutral faces as significantly more untrustworthy than L-BPD at both time periods. Negative and ambiguous trustworthiness pairing conditions led to higher ratings of untrustworthiness, whereas trustworthy and mixed descriptors led to lower ratings of untrustworthiness. Learning enhanced the amplitude of an early sensory event-related potential (ERP) component (i.e., P1) for both groups. The slow-wave ERP, an index of sustained attention, revealed greater focus after learning to trustworthy descriptors in H-BPD and to untrustworthy descriptors in L-BPD. H-BPD utilized greater effort to overcome an inherent mistrust bias and L-BPD to overcome unexpected untrustworthy information.

Transference-Focused Psychotherapy and Trust Processing in BPD: Exploring Possible Mechanisms of Change.

Individuals with borderline personality disorder (BPD) struggle to identify whom they can safely trust, and this struggle contributes to profound emotional turmoil in their close relationships. Transference-focused psychotherapy (TFP) is an application of object relations theory (ORT) that posits that polarized mental representations of self and other define the personality organization of BPD. TFP aims to utilize a clear treatment frame coupled with an analysis of the therapeutic relationship (i.e., the transference) to help individuals with BPD integrate their polarized mental representations. Improvement in the capacity to trust others is inherent in the mechanisms of change in TFP. In this article, a social cognitive model of trust processing provides a new lens through which we formulate how TFP may enhance trust processing in BPD. Recent evidence from randomized clinical trials supports the argument that TFP may intervene with BPD in a way that is concordant with uniquely improved trust processing.

Interpersonal Trust and Borderline Personality Disorder: Insights From Clinical Practice and Research: Introduction.

Individuals suffering from borderline personality disorder (BPD) show a pervasive sense that others cannot be trusted, are vulnerable to negative therapeutic reactions, and can oscillate between idealized and persecutory interactions with others. These trust processing impairments impact both the immediate and wider social milieu of individuals with BPD, including therapist-patient interactions. Recently, research started unraveling the social-cognitive mechanisms of these impairments in BPD. In this Special Issue, we attempt to close the gap between research findings and clinical theories on trust processing impairment in BPD. The first section includes five original studies on trust processing in BPD. The second section includes five articulations of trust processing impairment as a treatment target in evidence-based treatments for BPD and as an indispensable "common factor" in the treatment of BPD. These cutting-edge research and clinical contributions advance a potential integrative, clinical science framework for conceptualizing and intervening effectively with those who struggle with BPD.

Evaluating Change in Transference, Interpersonal Functioning, and Trust Processes in the Treatment of Borderline Personality Disorder: A Single-Case Study Using Ecological Momentary Assessment.

Transference-focused psychotherapy (TFP) is an empirically supported treatment for borderline personality disorder (BPD) that improves functioning via targeting representations of self affectively relating to others, particularly as evoked in the therapeutic relationship. If change in TFP operates as theorized, then shifts in patterns of "self affectively relating to others" should be observed in the transference prior to shifts in daily relationships. Using ecological momentary assessment (EMA), a patient with BPD rated daily interpersonal events for 2-week periods during 18 months of TFP; at 9 and 18 months these ratings included interactions with the therapist. Results suggest that positive perceptions of her therapist that ran counter to her negatively biased perception in other relationships preceded changes in her perceptions of others. EMA shifts corresponded to improvements in self-reported symptoms, interview-based personality functioning, and therapist assessments. Implications for assimilation of a trusting experience with the therapist as a mechanism of change in TFP are discussed.

Rejection Distress Suppresses Medial Prefrontal Cortex in Borderline Personality Disorder.

BACKGROUND: Borderline personality disorder (BPD) is characterized by an elevated distress response to social exclusion (i.e., rejection distress), the neural mechanisms of which remain unclear. Functional magnetic resonance imaging studies of social exclusion have relied on the classic version of the Cyberball task, which is not optimized for functional magnetic resonance imaging. Our goal was to clarify the neural substrates of rejection distress in BPD using a modified version of Cyberball, which allowed us to dissociate the neural response to exclusion events from its modulation by exclusionary context. METHODS: Twenty-three women with BPD and 22 healthy control participants completed a novel functional magnetic resonance imaging modification of Cyberball with 5 runs of varying exclusion probability and rated their rejection distress after each run. We tested group differences in the whole-brain response to exclusion events and in the parametric modulation of that response by rejection distress using mass univariate analysis. RESULTS: Although rejection distress was higher in participants with BPD (F1,40 = 5.25, p = .027, η2 = 0.12), both groups showed similar neural responses to exclusion events. However, as rejection distress increased, the rostromedial prefrontal cortex response to exclusion events decreased in the BPD group but not in control participants. Stronger modulation of the rostromedial prefrontal cortex response by rejection distress was associated with higher trait rejection expectation, r = -0.30, p = .050. CONCLUSIONS: Heightened rejection distress in BPD might stem from a failure to maintain or upregulate the activity of the rostromedial prefrontal cortex, a key node of the mentalization network. Inverse coupling between rejection distress and mentalization-related brain activity might contribute to heightened rejection expectation in BPD.

Identifying Splitting Through Sentiment Analysis.

In Kernerg's Object Relations Theory model of personality pathology, splitting, the mutual polarization of aspects of experience, is thought to result in a failure of identity integration. The authors sought to identify a clinician-independent, automated measure of splitting by examining 54 subjects' natural speech. Splitting in these individuals, recruited from the community, was investigated and evaluated with a shortened version of the Structured Interview of Personality Organization (STIPO-R). A type of automated sentiment textual analysis called VADER was applied to transcripts from the section of the STIPO-R that probes identity integration. Higher variability in speech valence, more negative minimum valence, and more frequent shifts in valence polarity were associated with more severe identity disturbance. The authors concluded that the degree of splitting elicited during the description of self and others is related to the degree of identity disturbance, and to the degree of negativity and instability of these descriptions of self and others.

A unifying translational framework to advance treatment research for comorbid PTSD and substance use disorders.

We provide a unifying translational framework that can be used to synthesize extant lines of human laboratory research in four neurofunctional domains that underlie the co-occurrence of posttraumatic stress and substance use disorders (PTSD+SUD). We draw upon the Alcohol and Addiction Research Domain Criteria (AARDOC) to include executive functioning, negative emotionality, reward, and added social cognition from the National Institute of Mental Health (NIMH) Research Domain Criteria into our framework. We review research findings across each of the four domains, emphasizing human experimental studies in PTSD, SUD, and PTSD+SUD for each domain. We also discuss the implications of research findings for treatment development by considering new ways of conceptualizing risk factors and outcomes at the level of the individual patient, which will enhance treatment matching and advance innovations in intervention.

Referential Activity Differentially Mediates Expression of Positive and Negative Emotions in Borderline Personality Disorder.

Borderline Personality Disorder (BPD) is a high risk and prevalent personality disorder that is associated with increased negative emotions, decreased positive emotions, and impairments in symbolization and impaired reflective functioning. These dimensions, while they may impact one another, have not been investigated concurrently from qualitative, linguistic narratives. We hypothesized a BPD group would have lower expression of positive emotions and greater expression of negative emotions and less reflective function than healthy controls. Additionally, we explored the role of referential activity (an index of symbolic capacity) between BPD and healthy controls in the context of valenced emotional expression. An adult, female BPD group (n = 13) and a demographically matched healthy control group (n = 14) were recruited and administered the Adult Attachment Interview and/or the Object Relations Inventory. Computerized text analyses were used to assess positive emotion and negative emotion, the Weighted Referential Activity Dictionaries to assess referential activity, and the Computerized Reflective Function dictionary. On the Object Relations Inventory, the BPD group expressed more frequent negative emotions and less frequent positive emotions; on the Adult Attachment Interview, the BPD group exhibited less expression of positive emotions. There were no differences between BPD and controls on referential activity or reflective functioning on either interview. However, BPD status fully mediated the significant relationship between referential activity and negative emotion expression. The BPD group utilized more referential activity when expressing negative emotions than controls. Conversely, the control group utilized more referential activity when expressing positive emotions than controls. Referential activity seems to play an important role in explaining the BPD versus control difference in valenced linguistic emotional expression. Furthermore, these results suggest the object relations inventory elicits more robust linguistic features relevant to BPD.

Trustworthiness appraisal deficits in borderline personality disorder are associated with prefrontal cortex, not amygdala, impairment.

BACKGROUND: Borderline Personality Disorder (BPD) is associated with sensitivity to signals of interpersonal threats and misplaced trust in others. The amygdala, an integral part of the threat evaluation and response network, responds to both fear- and trust-related stimuli in non-clinical samples, and is more sensitive to emotional stimuli in BPD compared to controls. However, it is unknown whether the amygdalar response can account for deficits of trust and elevated sensitivity to interpersonal threat in BPD. METHODS: Facial stimuli were presented to 16 medication-free women with BPD and 17 demographically-matched healthy controls (total n = 33). Participants appraised fearfulness or trustworthiness of the stimuli while BOLD fMRI was obtained. RESULTS: Though BPD participants judged stimuli as less trustworthy compared to controls, trustworthiness did not correlate with amygdalar activity in either group. Trustworthiness correlated with prefrontal regional activity in the insula and lateral prefrontal cortex. Prefrontal BOLD activity while appraising trustworthiness was smaller in BPD compared to controls, and the size of the reduction was proportional to each participant's response bias. CONCLUSIONS: Neural substrates of trustworthiness appraisal are associated with the lateral prefrontal cortex and insula, not amygdala, suggesting that untrustworthy stimuli do not elicit a subcortical threat response. Current models of BPD and its treatment may need to include a focus on improving impairments in frontally mediated trustworthiness appraisal in addition to amygdala- driven emotional hyper-reactivity.

Hypothalamic-pituitary-adrenal axis functioning in borderline personality disorder: A meta-analysis.

Borderline Personality Disorder (BPD) has been associated with altered hypothalamic-pituitary-adrenal (HPA) axis functioning. However, evidence is inconsistent. Therefore, the present series of meta-analyses aimed to quantify HPA axis functioning in BPD patients based on singular and continuous cortisol assessments and measures of reactivity to pharmacological and psychosocial stress. Case-control studies comparing adult BPD patients and healthy and clinical controls were considered for inclusion. The search resulted in 804 publications, of which 37 studies (k = 81; BPD n = 803, controls n = 1092) were included. Analyses were based on random effect models using standardized mean differences. BPD patients displayed elevated continuous cortisol output and blunted cortisol following psychosocial challenges. Singular cortisol assessments and cortisol after pharmacological challenges were not significantly different. Meta-analyses were limited by inconsistent reporting in individual studies and small samples for some comparisons. Due to the debilitating nature of stress-related symptoms in BPD, more research on elevated continuous cortisol output and blunted cortisol responses to psychosocial stress is warranted.

Social Cognition and Borderline Personality Disorder: Splitting and Trust Impairment Findings.

The Borderline personality disorder (BPD) diagnosis has its origins in the concept of borderline personality organization (BPO). BPO is rooted in psychoanalytic object relations theory (ORT) which conceptualizes BPD and BPO to exhibit a propensity to view significant others as either idealized or persecutory (splitting) and a trait-like paranoid view of interpersonal relations. From the ORT model, those with BPD think that they will ultimately be betrayed, abandoned, or neglected by significant others, despite periodic idealizations. This article synthesizes the extant literature splitting and trust impairments in BPD, identifies avenues for further investigation, and discusses the relative promise of different methods to evaluate these clinical processes.

Regulation of threat in post-traumatic stress disorder: Associations between inhibitory control and dissociative symptoms.

The current study investigated links between trauma exposure, Post-traumatic Stress Disorder (PTSD) symptoms, and inhibitory control assessed using a modified version of the visual flanker task. The study had three aims: (1) specifically confirm general non-affective deficits in sustained attention in PTSD; (2) probe the influence of threatening and trauma-related stimuli on inhibitory control; and (3) explore neural correlates connecting PTSD, facets of dissociation, and inhibitory control. Participants with PTSD (n = 16), trauma-exposed individuals without PTSD (TE; n = 14), and healthy controls (n = 15) discriminated line orientations while ignoring temporally flanking lines and images depicting threatening or non-threatening scenes or faces. Electrophysiological recordings were made during task performance. Relative to TE participants, PTSD participants had poor sustained non-affective attention, but nevertheless exhibited greater inhibition of distractors (i.e., high event-related potential [ERP] Rejection Positivity [RP]) to threatening (versus non-threatening) stimuli. RP was associated with greater self-reported depersonalization in PTSD participants, but with less depersonalization in TE participants. Dipole source analysis localized RP to the posterior cingulate cortex in both PTSD and TE (and healthy controls), but with an additional source in the ventromedial prefrontal cortex in TE, components of the default mode network. Results suggest a paradox in the executive control of distraction in PTSD: Whereas individuals with PTSD experience a general impairment in non-affective inhibitory control, their enhanced control of threat is associated with more severe symptoms of dissociation.

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

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

Romantic relationship dysfunction in borderline personality disorder-a naturalistic approach to trustworthiness perception.

Patients with borderline personality disorder (BPD) suffer greatly from their unstable interpersonal relationships. Studies on explanatory mechanisms driving social dysfunctions in patients' real-life relationships are, however, lacking. Here, we aimed to investigate one of the most central aspects of close relationships, interpersonal trust, in romantic relationships of persons with BPD. We tested the hypothesis that patients with BPD show unstable trustworthiness perception toward their partner, which we expected to be most pronounced after a relationship-threatening situation. Thirty-one heterosexual couples in which the women were diagnosed with BPD and 36 healthy control (HC) couples (total N = 134) each discussed three different topics that where (a) neutral (favorite films), (b) personally threatening (personal fears), and (c) relationship threatening (possible reasons for separation from partner). Trustworthiness appraisal of the partner was assessed after each conversation by self-report. BPD patients did not differ from HC women on trustworthiness perception after the neutral conversation but reported diminished trustworthiness perception after both threatening situations compared to HCs. BPD patients' trustworthiness perception was by trend decreased after the separation versus fear condition. The perceived tenderness in the relationship was a protective factor. The inability to maintain a stable image of a trustworthy partner during threatening situations might lead to difficulties in interpersonal relationships of patients with BPD. Although relationship threats possibly play a particular role in this context, trustworthiness perception decreases are not limited to this kind of threat. (PsycINFO Database Record

Improvements in Executive Attention, Rumination, Cognitive Reactivity, and Mindfulness Among High-Suicide Risk Patients Participating in Adjunct Mindfulness-Based Cognitive Therapy: Preliminary Findings.

OBJECTIVE: To test changes to cognitive functioning among high-suicide risk outpatients participating in an adjunct mindfulness-based intervention combining mindfulness-based cognitive therapy and safety planning (MBCT-S). DESIGN: Ten outpatients with a 6-month history of suicide attempt or active suicidal ideation plus suicidal ideation at study entry received 9 weeks of adjunct group-based MBCT-S. Executive attention, sustained attention, visual memory, and semantic memory encoding were measured by neuropsychological assessment. Rumination, mindfulness, cognitive reactivity (defined as the tendency towards depressogenic information processing and thought content in response to mild mood deterioration), and self-compassion were assessed using self-report measures. Changes in pre- to post-treatment functioning on these constructs were analyzed by using dependent t-tests. Where significant improvements were found, correlations between changes to cognitive functioning and depression and suicidal ideation during treatment were calculated. RESULTS: Executive attention improved with MBCT-S in high-suicide risk outpatients (Stroop interference effect = 0.39 [standard deviation (SD), 27] at baseline and 0.27 (SD, 0.15) at post-treatment, t[9] = 2.35, p = 0.04, d = 0.75). One mindfulness skill, acting with awareness, increased with MBCT-S (average change in Five Facet Mindfulness Questionnaire-acting with awareness subscale score with treatment, 3.3 [SD, 3.0], t[9] = 3.46, p < 0.01, d = 1.1). Self-reported rumination and cognitive reactivity to suicidality and hopelessness decreased among participants (Ruminative Responses Brooding subscale score change, -3.4 [SD, 1.1], t[9] = 10, p < 0.001, d = 3.2; Leiden Index of Depression Sensitivity-Revised-Hopelessness/Suicidality subscale score change, -3 [SD, 2.7], t[9] = 3.56, p < 0.01, d = 1.1). None of these changes were related to improvements in depression or reductions in suicidal ideation during treatment. CONCLUSIONS: Findings from the present pilot study suggest that treatment with MBCT-S may improve cognitive deficits specific to suicide ideators and attempters among depressed patients. Future controlled trials using follow-up assessments are needed to determine the specificity of these improvements in cognitive functioning to MBCT-S and their durability and to formally test whether the observed improvements in cognitive functioning explain MBCT-S treatment gains.

The specificity of mental pain in borderline personality disorder compared to depressive disorders and healthy controls.

BACKGROUND: Individuals with Borderline Personality Disorder (BPD) may experience a qualitatively distinct depression which includes "mental pain." Mental pain includes chronic, aversive emotions, negative self-concept, and a sense of pervasive helplessness. The present study investigated whether mental pain is elevated in BPD compared to Depressive Disorders (DD) without BPD. METHODS: The Orbach and Mikulincer Mental Pain Scale (OMMP) was administered to BPD (N = 57), DD (N = 22), and healthy controls (N = 31). The OMMP assesses total mental pain, comprised of nine subtypes: irreversibility, loss of control, narcissistic wounds, emotional flooding, freezing, self-estrangement, confusion, social distancing, and emptiness. Co-occurring psychiatric diagnoses, depression severity, and other potentially confounding clinical and demographic variables were also assessed. RESULTS: The total Mental Pain score did not differentiate BPD from DD. Moreover, most of the subscales of the OMMP were not significantly different in BPD compared to DD. However, the elevation of mental pain subscale "narcissistic wounds," characterized by feeling rejected and having low self-worth, was a specific predictor of BPD status and the severity of BPD symptoms. CONCLUSION: On OMMP total score, mental pain was similarly elevated in BPD and DD. However, the narcissistic wounds sub-type of mental pain was a sensitive and specific diagnostic indicator of BPD and, therefore, may be an important aspect of BPD in need of increased focus in assessment and theoretical models.

Facial trustworthiness perception bias elevated in individuals with PTSD compared to trauma exposed controls.

Posttraumatic stress disorder (PTSD) research has focused largely on fear processing. However, interpersonal trauma exposure can also impact interpersonal functioning and the perception of the trustworthiness of others. The present study examined facial perceptions of fearfulness and trustworthiness in individuals with PTSD (n=29), trauma-exposed without PTSD (n=19), and healthy controls (n=18). The PTSD group was hypothesized to exhibit a bias to perceive more fear and untrustworthiness in faces relative to controls. Participants rated the level of fearfulness or trustworthiness of faces that were parametrically morphed along a fear or trustworthiness dimension. The PTSD group was biased to perceive faces as more trustworthy compared to the trauma-exposed healthy controls, yet there were no differences between groups in fear processing. A trustworthiness bias in PTSD may represent a vulnerability factor. Conversely, lower trustworthiness perception may represent a protective disposition in trauma-exposed individuals who do not develop PTSD. Differences in the perception of trustworthiness may be an aspect of social perception that is independent of the fear processing abnormalities observed in PTSD.

Rejection sensitivity is a mediator between borderline personality disorder features and facial trust appraisal.

Individuals with borderline personality disorder (BPD) fear abandonment and exhibit instability in their close relationships. These interpersonal difficulties may be influenced by the propensity to interpret neutral social stimuli (e.g., nonemotional faces) as untrustworthy. This study evaluated the hypothesis that BPD features are associated with attributions of untrustworthiness to neutral faces. Additionally, the authors hypothesized that the trait of rejection sensitivity (RS) is also associated with BPD features and mediates the relationship between BPD features and untrustworthy facial trait appraisal. An undergraduate, nonclinical sample (N = 95) was assessed for BPD features, RS, and trust appraisal of neutral faces. Higher BPD features were associated with lower ratings of trustworthiness of the faces and higher scores on RS. Furthermore, as hypothesized, the association between BPD features and trust appraisal was mediated by RS. Results are discussed in the context of a proposed model of the social cognitive mechanisms of interpersonal hypersensitivity in BPD.

Facial trust appraisal negatively biased in borderline personality disorder.

Borderline personality disorder (BPD) is characterized by unstable interpersonal relationships and intense concerns regarding abandonment and rejection. Previous studies suggest that these and other symptoms of BPD may have their origin in a greater appraisal of untrustworthiness in others. However, it is not known whether this is a result of a heightened sensitivity to trust related stimuli, an improved ability to discriminate between such stimuli, or a response bias. Furthermore, impairment in facial fear appraisal may influence trust appraisal. Healthy controls and individuals diagnosed with BPD appraised human faces that were parametrically varied along either a trust or fear dimension. The BPD group exhibited a response bias to rate the untrustworthiness of facial stimuli higher compared to controls, but there were no significant differences in the discriminability or sensitivity of trustworthiness between groups. Furthermore, ambiguous trust decisions were associated with longer response times (RTs) in individuals with BPD relative to controls. Individuals with BPD have a facial appraisal bias specific to untrustworthiness that does not co-occur with impairments in the appraisal of fear.

Development and criterion validity of a computerized text analysis measure of reflective functioning.

The Reflective Functioning scale (RF) is a narrative-based assessment of the capacity to coherently conceptualize one's own and others' subjective motivations, emotions, beliefs, and desires. We report the preliminary results of an effort to develop a computerized text analysis version (CRF) of the RF assessment system. A sample of 113 clinical and non-clinical Adult Attachment Interviews (AAI) were utilized to develop the CRF measure. Using the Marker Approach (Mergenthaler & Bucci, 1999), 54 linguistic markers of high RF language were identified. The associations between CRF and RF were significant in both a clinical sample of patients diagnosed with Borderline Personality Disorder (BPD) (Spearman rho=.57, p<.0001) and a non-clinical sample of adults (Spearman rho=.57, p=.002). These results suggest that a CRF rating scale is feasible, has preliminary criterion validity, and, therefore, has potential to facilitate the efficient assessment of RF.