Falk Mancke

Aggression in borderline personality disorder: a multidimensional model

This article proposes a multidimensional model of aggression in borderline personality disorder (BPD) from the perspective of the biobehavioral dimensions of affective dysregulation, impulsivity, threat hypersensitivity, and empathic functioning. It summarizes data from studies that investigated these biobehavioral dimensions using self-reports, behavioral tasks, neuroimaging, neurochemistry as well as psychophysiology, and identifies the following alterations: (a) affective dysregulation associated with prefrontal-limbic imbalance, enhanced heart rate reactivity, skin conductance, and startle response; (b) impulsivity also associated with prefrontal-limbic imbalance, central serotonergic dysfunction, more electroencephalographic slow wave activity, and reduced P300 amplitude in a 2-tone discrimination task; (c) threat hypersensitivity associated with enhanced perception of anger in ambiguous facial expressions, greater speed and number of reflexive eye movements to angry eyes (shown to be compensated by exogenous oxytocin), enhanced P100 amplitude in response to blends of happy versus angry facial expressions, and prefrontal-limbic imbalance; (d) reduced cognitive empathy associated with reduced activity in the superior temporal sulcus/gyrus and preliminary findings of lower oxytocinergic and higher vasopressinergic activity; and (e) reduced self-other differentiation associated with greater emotional simulation and hyperactivation of the somatosensory cortex. These biobehavioral dimensions can be nicely linked to conceptual terms of the alternative Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) model of BPD, and thus to a multidimensional rather than a traditional categorical approach.

Brain Mechanisms Underlying Reactive Aggression in Borderline Personality Disorder—Sex Matters

BACKGROUND Aggression in borderline personality disorder (BPD) is thought to be mediated through emotion dysregulation via high trait anger. Until now, data comparing anger and aggression in female and male patients with BPD have been widely missing on the behavioral and particularly the brain levels. METHODS Thirty-three female and 23 male patients with BPD and 30 healthy women and 26 healthy men participated in this functional magnetic resonance imaging study. We used a script-driven imagery task consisting of narratives of both interpersonal rejection and directing physical aggression toward others. RESULTS While imagining both interpersonal rejection and acting out aggressively, a sex × group interaction was found in which male BPD patients revealed higher activity in the left amygdala than female patients. In the aggression phase, men with BPD exhibited higher activity in the lateral orbitofrontal and dorsolateral prefrontal cortices compared with healthy men and female patients. Positive connectivity between amygdala and posterior middle cingulate cortex was found in female patients but negative connectivity was found in male patients with BPD. Negative modulatory effects of trait anger on amygdala-dorsolateral prefrontal cortex and amygdala-lateral orbitofrontal cortex coupling were shown in male BPD patients, while in female patients trait anger positively modulated dorsolateral prefrontal cortex-amygdala coupling. Trait aggression was found to positively modulate connectivity of the left amygdala to the posterior thalamus in male but not female patients. CONCLUSIONS Data suggest poor top-down adjustment of behavior in male patients with BPD despite their efforts at control. Female patients appear to be less aroused through rejection and to successfully dampen aggressive tension during the imagination of aggressive behavior.

Gender differences in aggression of borderline personality disorder.

Aggression is a core feature of borderline personality disorder (BPD). Well-replicated results from the general population indicate that men engage in aggression more frequently than women. This article addresses the question of whether gender also influences aggression in BPD, and whether the neurobiological mechanisms underlying aggressive behavior differ between male and female BPD patients. Data show that most self-reports, interviews and behavioral tasks investigating samples of BPD patients do not find enhanced aggressiveness in male patients, suggesting that BPD attenuates rather than aggravates gender differences usually present in the general population. Neurobiological studies comparing BPD patients with gender-matched healthy controls, however, reveal a number of interesting gender differences: On the one hand, there are well-replicated findings of reduced amygdala and hippocampal gray matter volumes in female BPD patients, while these findings are not shared by male patients with BPD. On the other hand, only male BPD patients exhibit reduced gray matter volume of the anterior cingulate cortex, increased gray matter volume of the putamen, reduced striatal activity during an aggression task, and a more pronounced deficit in central serotonergic responsivity. These neurobiological findings point to a particular importance of impulsivity for the aggression of male BPD patients. Limitations include the need to control for confounding influences of comorbidities, particularly as male BPD patients have been consistently found to show higher percentages of aggression-predisposing comorbid disorders, such as antisocial personality disorder, than female BPD patients. In the future, studies which include systematic comparisons between females and males are warranted in order to disentangle gender differences in aggression of BPD patients with the aim of establishing gender-sensitive treatments where needed.

Deficits in pain perception in borderline personality disorder: results from the thermal grill illusion.

Abstract It is well documented that borderline personality disorder (BPD) is characterized by reduced pain sensitivity, which might be related to nonsuicidal self-injury and dissociative experiences in patients with BPD. However, it remains an open question whether this insensitivity relies at least partly on altered sensory integration or on an altered evaluation of pain or a combination of both. In this study, we used the thermal grill illusion (TGI), describing a painful sensation induced by the application of alternating cold and warm nonnoxious stimuli, in patients with either current or remitted BPD as well as matched healthy controls. Two additional conditions, applying warm or cold temperatures only, served as control. We further assessed thermal perception, discrimination, and pain thresholds. We found significantly reduced heat and cold pain thresholds for the current BPD group, as well as reduced cold pain thresholds for the remitted BPD group, as compared with the HC group. Current BPD patients perceived a less-intense TGI in terms of induced pain and unpleasantness, while their general ability to perceive this kind of illusion seemed to be unaffected. Thermal grill illusion magnitude was negatively correlated with dissociation and traumatization only in the current BPD patients. These results indicate that higher-order pain perception is altered in current BPD, which seems to normalize after remission. We discuss these findings against the background of neurophysiological evidence for the TGI in general and reduced pain sensitivity in BPD and suggest a relationship to alterations in N-methyl-D-aspartate neurotransmission.

Emotion Dysregulation and Trait Anger Sequentially Mediate the Association Between Borderline Personality Disorder and Aggression

Emotion dysregulation and trait anger are seen as central aspects of aggression in borderline personality disorder (BPD); their interplay in aggression of BPD, however, remains unclear. Using a cross-sectional design, we conducted a mediation analysis in a well-characterized sample of female and male BPD patients (n = 95). We found that emotion dysregulation and trait anger sequentially mediate the association between BPD and aggression. In accordance with major theories of BPD, emotion dysregulation may thus constitute an underlying factor that gives rise to anger and in turn to aggression in BPD. These findings may help to develop mechanism-based anti-aggressive interventions for patients with BPD, which should target emotion dysregulation and anger proneness.

Social Dysfunctioning and Brain in Borderline Personality Disorder

Interpersonal dysfunction is the most prominent and best discriminating characteristic in individuals with borderline personality disorder (BPD). Data from experimental psychopathology point to emotional lability, (auto-)aggression, threat hypersensitivity, poor chance of interpersonal repair, frequent misunderstandings and self/other diffusion as the most significant factors which contribute to the interpersonal derailments typical of BPD. Neuroscientific methods are suitable to elucidate the mechanisms which mediate deficient social functioning in BPD, i.e. affective dysregulation, impulsivity/disinhibition and poor social cognition as well as their neurobiological correlates. Low prefrontoamygdalar coupling together with low activity in inhibiting prefrontal areas, high activity in the mirror neuron system, low activity in the mentalizing circuit, and low anterior insular activity in case of social norm violations are the most significant functional neuroimaging findings that have been reported from individuals with BPD, up to now. In addition, peculiarities of facial emotion processing have been detected by means of psychophysiological methodology in BPD patients. Data have led to preliminary models of social dysfunctioning in BPD that have to be experimentally tested in the future, evolving neuroscience into an important tool to better understand what distresses patients with BPD when communicating with others.

Assessing the marks of change: how psychotherapy alters the brain structure in women with borderline personality disorder

BACKGROUND There is increasing evidence that psychotherapy can alter the function of the brain of patients with borderline personality disorder (BPD). However, it is not known whether psychotherapy can also modify the brain structure of patients with BPD. METHODS We used structural MRI data of female patients with BPD before and after participation in 12 weeks of residential dialectical behavioural therapy (DBT) and compared them to data from female patients with BPD who received treatment as usual (TAU). We applied voxel-based morphometry to study voxel-wise changes in grey matter volume over time. RESULTS We included 31 patients in the DBT group and 17 in the TAU group. Patients receiving DBT showed an increase of grey matter volume in the anterior cingulate cortex, inferior frontal gyrus and superior temporal gyrus together with an alteration of grey matter volume in the angular gyrus and supramarginal gyrus compared with patients receiving TAU. Furthermore, therapy response correlated with increase of grey matter volume in the angular gyrus. LIMITATIONS Only women were investigated, and groups differed in size, medication (controlled for) and intensity of the treatment condition. CONCLUSION We found that DBT increased grey matter volume of brain regions that are critically implicated in emotion regulation and higher-order functions, such as mentalizing. The role of the angular gyrus for treatment response may reside in its cross-modal integrative function. These findings enhance our understanding of psychotherapy mechanisms of change and may foster the development of neurobiologically informed therapeutic interventions.

The role of seeing blood in non-suicidal self-injury in female patients with borderline personality disorder

Patients with Borderline Personality Disorder (BPD) often engage in non-suicidal self-injury (NSSI), to reduce arousal levels under stress. However, the importance of seeing blood for the effect of NSSI is yet unknown. The present pilot study examined 20 female BPD patients and 20 healthy controls (HC) to assess the role of seeing blood on arousal, pain, urge for NSSI (ratings) and heart rate (continuously measured). Participants completed two sessions consisting of stress induction (forced mental arithmetics with white noise), followed by a seven second non-invasive pain stimulus with a blade to the volar forearm. At one session, only the painful blade stimulus was applied, at the other, artificial blood was added. For arousal, a significantly stronger decrease was revealed in the BPD than in the HC group, however with no significant effects between blood and non-blood conditions. Concerning urge for NSSI, the BPD showed a significantly greater decrease in blood condition over time than the HC group. Interestingly, heart rate decreased stronger over time in the HC group during the blood condition than in BPD. For tension relief by non-damaging mechanical painful stimulus the addition of visible blood showed neither subjective (arousal, urge for NSSI), nor objective (heart rate) advantages.

Amygdala structure and aggressiveness in borderline personality disorder

Aggressiveness is considered an important clinical feature of borderline personality disorder (BPD) and has been associated with alterations of the amygdala. However, studies that analyzed the exact location of amygdala alterations associated with aggressiveness in BPD or that systematically compared female and male BPD patients are missing. In the current study, we therefore investigated a sex-mixed sample of BPD patients and healthy volunteers and applied an automated segmentation method that allows the study of both, alterations of amygdala volume and localized amygdala shape. Volumetric results revealed no difference in amygdala volume between BPD patients and healthy volunteers, but a trend for a positive association between volume of the right amygdala and aggressiveness in male BPD patients. Analyses of amygdala shape showed a trend for a group by sex interaction effect in the left laterobasal amygdala, without a difference in subgroup analyses. Finally, regions of the left superficial and laterobasal amygdala of male BPD patients were positively associated with aggressiveness. In sum, our results emphasize the need to consider sex-specific effects and demonstrate a link between male BPD patients’ aggressiveness and amygdala regions that are particularly related to social information processing and associative emotional learning.

Effects of a Painful Stimulus on Stress Regulation in Male Patients With Borderline Personality Disorder: A Pilot Study

Pain processing in relation to stress has so far not been investigated in male patients with borderline personality disorder (BPD). This experimental pilot study examined 17 male BPD patients and 20 male healthy controls (HCs) to assess the effects of a pain stimulus on arousal, aggression, pain (ratings), and heart rate. At baseline, BPD patients showed significantly higher arousal and aggression; however, there was no significant difference in heart rate compared to the HC group. Following stress induction, a noninvasive mechanical pain stimulus was applied. No significant differences in pain ratings or heart rates were found between the groups. For arousal, a significantly stronger decrease was revealed in the BPD group compared to the HC group (t = 2.16, p = .038). Concerning aggression, the BPD group showed a significantly greater decrease after the pain stimulus than the HC group (t = 3.25, p = .002). This data showed that nonsuicidal self-injury can reduce arousal and aggression in male BPD.