Restructuring the final year of the model study programme MaReCuM at the Medical Faculty Mannheim: the academic quarter in ambulatory medicine.

Introduction: To reflect the ever-growing importance of outpatient care in medical education, MaReCuM - a reformed curriculum, also referred to as a model study programme - was introduced at the Medical Faculty Mannheim in 2006. It divided the final year of medical study into quarters and added a mandatory quarter dedicated to ambulatory medicine. This project report presents our experiences, the costs and the evaluation results connected with making specific changes to the final year of undergraduate medical study. Project description: The final-year quarter in ambulatory medicine, taught at the Medical Faculty's outpatient teaching placements, allows final-year medical students to gather practical experience in one of four elective areas in outpatient care. The parallel coursework encompasses interactive case presentations and practical reviews. Relevant curricular content on ambulatory medicine is then tested in the oral/practical section of the M3 medical examination. Results: Students are very satisfied with the academic quality of the final-year quarter in ambulatory medicine. Restructuring the final year, generating the concept and recruiting teaching placements at outpatient facilities required additional full-time positions in the beginning. Discussion: The processes of reforming MaReCuM have not only contributed to a stronger recognition of ambulatory medicine in the final year and in the clinical phase of study, but have also enabled broader opportunities for focussing individual choices during medical education. A high caliber of academics in the quarter in ambulatory medicine can be achieved with a calculable amount of organisational effort. Conclusion: Anchoring a curriculum on ambulatory medicine in medical education is possible through restructuring the final year and is received positively by students. The success of MaReCuM demonstrates the feasibility of the recommendations made by the German Council of Science and Humanities (Wissenschaftsrat).

A negative bias in decoding positive social cues characterizes emotion processing in patients with symptom-remitted Borderline Personality Disorder.

BACKGROUND: Impairments in the domain of interpersonal functioning such as the feeling of loneliness and fear of abandonment have been associated with a negative bias during processing of social cues in Borderline Personality Disorder (BPD). Since these symptoms show low rates of remission, high rates of recurrence and are relatively resistant to treatment, in the present study we investigated whether a negative bias during social cognitive processing exists in BPD even after symptomatic remission. We focused on facial emotion recognition since it is one of the basal social-cognitive processes required for successful social interactions and building relationships. METHODS: Ninety-eight female participants (46 symptom-remitted BPD [r-BPD]), 52 healthy controls [HC]) rated the intensity of anger and happiness in ambiguous (anger/happiness blends) and unambiguous (emotion/neutral blends) emotional facial expressions. Additionally, participants assessed the confidence they experienced in their own judgments. RESULTS: R-BPD participants assessed ambiguous expressions as less happy and as more angry when the faces displayed predominantly happiness. Confidence in these judgments did not differ between groups, but confidence in judging happiness in predominantly happy faces was lower in BPD patients with a higher level of BPD psychopathology. CONCLUSIONS: Evaluating social cues that signal the willingness to affiliate is characterized by a negative bias that seems to be a trait-like feature of social cognition in BPD. In contrast, confidence in judging positive social signals seems to be a state-like feature of emotion recognition in BPD that improves with attenuation in the level of acute BPD symptoms.

Difficulties with being socially accepted: An experimental study in borderline personality disorder.

Anxious preoccupation with real or imagined abandonment is a key feature of borderline personality disorder (BPD). Recent experimental research suggests that patients with BPD do not simply show emotional overreactivity to rejection. Instead, they experience reduced connectedness with others in situations of social inclusion. Resulting consequences of these features on social behavior are not investigated yet. The aim of the present study was to investigate the differential impact of social acceptance and rejection on social expectations and subsequent social behavior in BPD. To this end, we developed the Mannheim Virtual Group Interaction Paradigm in which participants interacted with a group of computer-controlled avatars. They were led to believe that these represented real human coplayers. During these interactions, participants introduced themselves, evaluated their coplayers, assessed their social expectations and received feedback signaling either acceptance or rejection by the alleged other participants. Subsequently, participants played a modified trust game, which measured cooperative and aggressive behavior. Fifty-six nonmedicated BPD patients and 56 healthy control participants were randomly and double-blindly assigned to either the group-acceptance or group-rejection condition. BPD patients showed lower initial expectations of being socially accepted than healthy controls. After repeated presentation of social feedback, they adjusted their expectations in response to negative, but not to positive feedback. After the experience of social acceptance, BPD patients behaved less cooperatively. These experimental findings point to a clinically relevant issue in BPD: Altered cognitive and behavioral responses to social acceptance may hamper the forming of stable cooperative relationships and negatively affect future interpersonal relationships. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Behavioural mimicry and loneliness in borderline personality disorder.

INTRODUCTION: Interpersonal problems together with feelings of intense loneliness constitute a core symptom domain in borderline personality disorder (BPD). Mimicry is one social behaviour that serves the forming of social affiliation and building a sense of belonging. In the present study, we investigated whether behavioural mimicry is altered in BPD and whether it is linked to the patient's feeling of loneliness. METHODS: Individuals with BPD (N = 26) and healthy participants (HC, N = 25) performed a finger tapping task with a congruent or incongruent finger movement displayed preceding the presentation of the task relevant stimulus. Additional trials showing an immobile hand were used as a control condition. Mimicry strength was estimated as response facilitation after congruent and response interference after incongruent cues. RESULTS: Both HC and BPD patients showed facilitated responses after congruent finger movements. Only BPD patients exhibited interference by incongruent cues. The lonelier the BPD patients felt, the weaker was the interference of the incongruent cues. In contrast, interference increased with the level of loneliness in the HC group. CONCLUSIONS: Behavioural mimicry was increased in BPD. However, this effect was less pronounced in those BPD patients who reported the highest levels of loneliness. Our findings emphasize that mimicry is a complex construct and only some of the involved processes are altered in BPD. Future studies must further disentangle the contribution of cognitive and social cognitive processes, address a potential causality in the link between loneliness and mimicry in BPD, and relate alterations of mimicry to interpersonal dysfunction during every-day life.

Generalisation of fear in PTSD related to prolonged childhood maltreatment: an experimental study.

BACKGROUND: Fear responses are particularly intense and persistent in post-traumatic stress disorder (PTSD), and can be evoked by unspecific cues that resemble the original traumatic event. Overgeneralisation of fear might be one of the underlying mechanisms. We investigated the generalisation and discrimination of fear in individuals with and without PTSD related to prolonged childhood maltreatment. METHODS: Sixty trauma-exposed women with (N = 30) and without (N = 30) PTSD and 30 healthy control participants (HC) underwent a fear conditioning and generalisation paradigm. In a contingency learning procedure, one of two circles of different sizes was associated with an electrical shock (danger cue), while the other circle represented a safety cue. During generalisation testing, online risk ratings, reaction times and fear-potentiated startle were measured in response to safety and danger cues as well as to eight generalisation stimuli, i.e. circles of parametrically varying size creating a continuum of similarity between the danger and safety cue. RESULTS: The increase in reaction times from the safety cue across the different generalisation classes to the danger cue was less pronounced in PTSD compared with HC. Moreover, PTSD participants expected higher risk of an aversive event independent of stimulus types and task. CONCLUSIONS: Alterations in generalisation constitute one part of fear memory alterations in PTSD. Neither the accuracy of a risk judgement nor the strength of the induced fear was affected. Instead, processing times as an index of uncertainty during risk judgements suggested a reduced differentiation between safety and threat in PTSD.

Borderline Personality Disorder Features and Sensitivity to Injustice.

Hypersensitivity to injustice has been proposed to contribute to interpersonal dysfunction in borderline personality disorder (BPD). We investigated whether BPD features are related to sensitivity to injustice and whether justice sensitivity mediates the relationship between BPD features and aggressive behavior. In an online survey, subjects reported justice sensitivity from the perspective of a victim, an observer, a beneficiary, and a perpetrator as well as BPD features and their own aggressive behavior. Justice sensitivity was higher in participants with a clinically relevant degree of BPD features when they evaluated injustice from the perspective of a victim or an observer. Victim sensitivity partially mediated the relationship between BPD features and the frequency of aggressive behavior. The present study provides first data on the important role of sensitivity to injustice in those with marked BPD features. Particularly, victim sensitivity with its close link to angry reactions may contribute to interpersonal problems in BPD.

Loneliness, social networks, and social functioning in borderline personality disorder.

Persistent loneliness is often reported by patients with borderline personality disorder (BPD). However, empirical studies investigating this aspect of BPD psychopathology are sparse. Studies from social psychology revealed that social isolation and low social functioning contribute to loneliness, that is, the subjective feeling of being alone. The aim of the present study was to contribute to the understanding of loneliness in BPD by investigating its relation to social isolation and functioning in different domains of life. Subjective experience of loneliness was measured in 80 women (40 BPD patients, 40 healthy controls) with the UCLA Loneliness Scale. Social isolation and social functioning were assessed with the Social Network Inventory and the Social Functioning Scale. In addition, we assessed global functioning with the Global Assessment of Functioning. BPD patients reported stronger feelings of loneliness compared to healthy participants. In general, the level of loneliness was linked to network size, social engagement, and prosocial behavior. Diversity of social networks and functioning in the domain of interpersonal communication were associated with the level of loneliness only in BPD. A reduced variety of roles in social life together with impairments in interpersonal communication were particularly relevant for the experience of loneliness in BPD, suggesting an indirect path to target this psychopathological feature in therapeutic interventions. However, both social isolation and social functioning were not sufficient to explain the severely increased loneliness experienced by these patients, stressing the need for further investigation of determinants of loneliness in this clinical population. (PsycINFO Database Record

Modification of Fear Memory by Pharmacological and Behavioural Interventions during Reconsolidation.

BACKGROUND: Dysfunctional fear responses play a central role in many mental disorders. New insights in learning and memory suggest that pharmacological and behavioural interventions during the reconsolidation of reactivated fear memories may increase the efficacy of therapeutic interventions. It has been proposed that interventions applied during reconsolidation may modify the original fear memory, and thus prevent the spontaneous recovery and reinstatement of the fear response. METHODS: We investigated whether pharmacological (propranolol) and behavioural (reappraisal, multisensory stimulation) interventions reduce fear memory, and prevent reinstatement of fear in comparison to a placebo control group. Eighty healthy female subjects underwent a differential fear conditioning procedure with three stimuli (CS). Two of these (CS+) were paired with an electric shock on day 1. On day 2, 20 subjects were pseudo-randomly assigned to either the propranolol or placebo condition, or underwent one of the two behavioural interventions after one of the two CS+ was reactivated. On day 3, all subjects underwent an extinction phase, followed by a reinstatement test. Dependent variables were US expectancy ratings, fear-potentiated startle, and skin conductance response. RESULTS: Differential fear responses to the reactivated and non-reactivated CS+ were observed only in the propranolol condition. Here, the non-reactivated CS+ evoked stronger fear-potentiated startle-responses compared to the placebo group. None of the interventions prevented the return of the extinguished fear response after re-exposure to the unconditioned stimulus. CONCLUSIONS: Our data are in line with an increasing body of research stating that the occurrence of reconsolidation may be constrained by boundary conditions such as subtle differences in experimental manipulations and instructions. In conclusion, our findings do not support a beneficial effect in using reconsolidation processes to enhance effects of psychotherapeutic interventions. This implies that more research is required before therapeutic interventions may benefit from a combination with reconsolidation processes.

Confidence in facial emotion recognition in borderline personality disorder.

Dysfunctions of social-cognitive processes such as the recognition of emotions have been discussed to contribute to the severe impairments of interpersonal functioning in borderline personality disorder (BPD). By investigating how patients with BPD experience the intensity of different emotions in a facial expression and how confident they are in their own judgments, the current study aimed at identifying subtle alterations of emotion processing in BPD. Female patients with BPD (N = 36) and 36 healthy controls were presented with faces that displayed low-intense anger and happiness or ambiguous expressions of anger and happiness blends. Subjects were asked to rate (a) the intensity of anger and happiness in each facial expression and (b) their confidence in their judgments. Patients with BPD rated the intensity of happiness in happy faces lower than did controls, but did not differ in regard to the assessment of angry or ambiguous facial stimuli or the rating of anger. They reported lower confidence in their judgments, which was particularly pronounced for the assessment of happy facial expressions. The reduced rating of happiness was linked to higher state anger, whereas the reduced confidence in the assessment of happy faces was related to stronger feelings of loneliness and the expectation of social rejection. Our findings suggest alterations in the processing of positive social stimuli that affect both the experience of the emotional intensity and the confidence subjects experience during their assessment. The link to loneliness and social rejection sensitivity points to the necessity to target these alterations in psychotherapeutical interventions.

Rejection sensitivity and symptom severity in patients with borderline personality disorder: effects of childhood maltreatment and self-esteem.

BACKGROUND: Interpersonal dysfunction in Borderline Personality Disorder (BPD) is characterized by an 'anxious preoccupation with real or imagined abandonment' (DSM-5). This symptom description bears a close resemblance to that of rejection sensitivity, a cognitive affective disposition that affects perceptions, emotions and behavior in the context of social rejection. The present study investigates the level of rejection sensitivity in acute and remitted BPD patients and its relation to BPD symptom severity, childhood maltreatment, and self-esteem. METHODS: Data were obtained from 167 female subjects: 77 with acute BPD, 15 with remitted BPD, and 75 healthy controls who were matched with the patients for age and education. The instruments used for assessment were the Rejection Sensitivity Questionnaire, the short version of the Borderline Symptom List, the Childhood Trauma Questionnaire, and the Rosenberg Self-Esteem Scale. RESULTS: Both acute and remitted BPD patients had higher scores on the Rejection Sensitivity Questionnaire than did healthy controls. Lower self-esteem was found to be positively correlated with both increased BPD symptom severity and higher rejection sensitivity, and mediated the relation between the two. History of childhood maltreatment did not correlate with rejection sensitivity, BPD symptom severity, or self-esteem. CONCLUSIONS: Our findings support the hypothesis that rejection sensitivity is an important component in BPD, even for remitted BPD patients. Level of self-esteem appears to be a relevant factor in the relationship between rejection sensitivity and BPD symptom severity. Therapeutic interventions for BPD would do well to target rejection sensitivity.

Emotion recognition in borderline personality disorder: effects of emotional information on negative bias.

BACKGROUND: Borderline Personality Disorder (BPD) is characterized by severe deficits in social interactions, which might be linked to deficits in emotion recognition. Research on emotion recognition abilities in BPD revealed heterogeneous results, ranging from deficits to heightened sensitivity. The most stable findings point to an impairment in the evaluation of neutral facial expressions as neutral, as well as to a negative bias in emotion recognition; that is the tendency to attribute negative emotions to neutral expressions, or in a broader sense to report a more negative emotion category than depicted. However, it remains unclear which contextual factors influence the occurrence of this negative bias. Previous studies suggest that priming by preceding emotional information and also constrained processing time might augment the emotion recognition deficit in BPD. METHODS: To test these assumptions, 32 female BPD patients and 31 healthy females, matched for age and education, participated in an emotion recognition study, in which every facial expression was preceded by either a positive, neutral or negative scene. Furthermore, time constraints for processing were varied by presenting the facial expressions with short (100 ms) or long duration (up to 3000 ms) in two separate blocks. RESULTS: BPD patients showed a significant deficit in emotion recognition for neutral and positive facial expression, associated with a significant negative bias. In BPD patients, this emotion recognition deficit was differentially affected by preceding emotional information and time constraints, with a greater influence of emotional information during long face presentations and a greater influence of neutral information during short face presentations. CONCLUSIONS: Our results are in line with previous findings supporting the existence of a negative bias in emotion recognition in BPD patients, and provide further insights into biased social perceptions in BPD patients.