Emotional sensitivity in youth with borderline personality pathology

Psychiatry Research 187 (2011) 234–240

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Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

Emotional sensitivity in youth with borderline personality pathology Martina Jovev a,⁎, Andrew Chanen a,b, Melissa Green c,d, Sue Cotton a, Tina Proffitt a, Max Coltheart e, Henry Jackson a,f a

Orygen Youth Health Research Centre, Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia Orygen Youth Health Clinical Program, Northwestern Mental Health, Melbourne, Australia School of Psychiatry, University of New South Wales, Sydney, Australia d Black Dog Institute, Prince of Wales Hospital, Randwick, Australia e Macquarie Centre for Cognitive Science, Macquarie University, Sydney, Australia f Department of Psychological Sciences, The University of Melbourne, Melbourne, Australia b c

a r t i c l e

i n f o

Article history: Received 18 January 2010 Received in revised form 3 November 2010 Accepted 8 December 2010 Keywords: Borderline personality disorder Affect Adolescence

a b s t r a c t If Borderline Personality Disorder (BPD) is characterized by an underlying emotional sensitivity, individuals with this disorder would be expected to demonstrate accurate identification of emotional expressions at earlier stages of expression (i.e., lower thresholds of facial expressivity across all emotional valences). Twenty-one outpatient youth (aged 15–24 years) meeting 3 or more DSM-IV BPD criteria and 20 communityderived participants (aged 15–24 years) with no history of psychiatric problems were tested on a measure of emotional sensitivity, the Face Morph Task. In this test faces morph from neutral to each of the six basic emotional expressions. The BPD group showed no evidence of heightened sensitivity to emotional facial expressions compared to the community control group (all P N 0.05 and effect sizes ranging from 0 to 0.6). They require comparable levels of emotional expressivity in order to correctly identify emotions. Therefore, emotional sensitivity might not be apparent early in the course of BPD. Rather, it might develop later in the course of the disorder or be present only in severe BPD. © 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Facial expressions of emotions are fundamental social emotional signals with a strong evolutionary bias and immediate implications for behaviour. Emotional expressions provide information about the intentions of others, personal relations, evoke emotional responses in others and serve as incentives for action (Keltner and Kring, 1998). For instance, sad expressions have been linked with promoting nurturance and inhibiting aggression and hostility in others, while angry expressions have been shown to reduce errant behaviour (e.g., breaking social rules and expectations) in observers. Dysfunction in either their own emotional displays or perception of emotions in others can disrupt or harm social relationships and self-management by eliciting adverse responses from others and failing to elicit supportive responses when needed. As such, aberrant processing and responding to facial emotional expressions might result in detrimental effects on social functioning. Emotion dysregulation lies at the core of Linehan's biosocial theory of BPD (Linehan, 1993), which is one of the most thoroughly delineated etiological models of borderline pathology (for other models, see: (Fonagy et al., 2000; Judd and McGlashan, 2003; Kernberg, 1967, 1975, ⁎ Corresponding author. Orygen Youth Health Research Centre, Locked Bag 10, Parkville, Victoria, Australia 3052. Tel.: +61 3 9342 2800; fax: +61 3 9387 3003. E-mail address: [email protected] (M. Jovev). 0165-1781/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2010.12.019

1976). The dysfunction proposed by Linehan is one of broad dysregulation across all aspects of emotional responding. Individuals with BPD display greater emotional sensitivity (low threshold for recognition of emotional stimuli), greater emotional reactivity (high amplitude of emotional responses), and longer duration of emotional responses (slower return to baseline arousal). BPD emerges from transactions between individuals with biological vulnerabilities and specific environmental influences (e.g., family environment). More specifically, impulsivity is seen as a predisposing vulnerability for both current and future difficulties with emotion regulation, resulting in dysregulation across cognitive processes, neurochemistry and physiology, facial and muscle reactions and emotion-linked actions (Crowell et al., 2009). There is some empirical support for this hypothesis. Individuals with BPD process information in a negatively biased way (Veen and Arntz, 2000; Meyer et al., 2004), remember more negatively salient words (and perhaps more negative memories) (Korfine and Hooley, 2000), are more sensitive to emotional stimuli (Frank and Hoffman, 1986; Ladisch and Feil, 1988), tend to rate faces as less friendly and more rejecting (Meyer et al., 2004) and have reduced facial emotional expressiveness to positive as well as negative stimuli (Renneberg et al., 2005). This is despite having autonomic arousal and startle responses comparable to the non-BPD control group (Herpertz et al., 1999; Herpertz et al., 2000; Herpertz et al., 2001) and better mental state discrimination based on the eye region of the face compared to community controls (Fertuck et al., 2009).

M. Jovev et al. / Psychiatry Research 187 (2011) 234–240

Recently, Domes et al. (2009) systematically reviewed six studies focusing on BPD patients' recognition and responding to facial stimuli. Four of these studies used static emotional expressions with somewhat varying results. In a predominantly female sample (66%), Levine et al. (1997) reported lower accuracy in recognising facial expression of anger, fear and disgust in the BPD group (n=30), compared to the nonpsychiatric comparison (n=40) group matched on age and education level. Similarly, Bland et al. (2004) found impaired recognition accuracy for fearful angry and sad faces in women with BPD. Minzenberg et al. (2006) compared outpatients with BPD (n=43, 88% female) to healthy controls (n=26, 89% female) on emotion recognition tasks across visual and auditory modalities (facial, prosodic, and integrated facial/prosodic). Patients with BPD showed normal ability to recognize isolated facial or prosodic emotions. They did, however, have impaired recognition of emotions in integrated facial/prosodic stimuli. Impaired discrimination of non-emotional facial features was also evident and might be related to some of the more serious symptoms of the disorder (e.g., interpersonal antagonism). The above studies used a multiple-choice answer format, where participants had to choose an answer from a list of alternatives. In contrast, Wagner and Linehan (1999) asked participants to describe the emotional state of the presented person. They examined recognition of emotional facial expressions among women diagnosed with BPD (n=21), compared to a group of women diagnosed with histories of childhood sexual abuse (n=21) and a group of women with no history of sexual abuse or BPD (n=20). Unlike the other studies, they found that the BPD group were accurate in recognising emotions, but had significantly heightened sensitivity towards recognition of fear. Nevertheless, the above studies using static emotional facial expressions have not clarified whether BPD patients show differences in accuracy of labelling specific emotions or have a different detection threshold for more ecologically valid ambiguous stimuli (i.e., facial stimuli not at 100% expression or facial stimuli with ambiguous blends of emotion). In order to simultaneously examine detection threshold and recognition accuracy for emotional faces, dynamic facial expressions need to be utilised. Moreover, recognition of emotions relies upon anatomically separable brain regions, depending on whether the stimuli were static or dynamic displays of facial affect and there is evidence that different types of knowledge about emotions may draw upon different neural systems (Adolphs, 2002; Adolphs et al., 2003). Temporal and limbic-related cortices may be important in retrieving information about emotions signalled by static stimuli, while parietal and frontal lobe areas may be more involved in retrieving knowledge about emotions signalled through dynamic movement (Adolphs et al., 2003). In addition, the role of brain areas mediating attention (e.g., inferior medial prefrontal cortex) are implicated for longer presentation times since multiple cognitive processes compete when a stimulus is presented for more than three seconds, such that the observer divides attention between emotions evoked by the stimulus and their secondary cognitive associations (Geday et al., 2007). Thus the difference between static and dynamic tasks may not only be in terms of stimulus presentation but also in the brain regions activated during the experimental task. Two studies of emotion processing in BPD to date have used dynamic facial expressions in their design. Lynch et al. (2006) demonstrated that participants with BPD (n = 20, 85% female) were significantly more likely to correctly identify facial affect (regardless of valence) at an earlier stage than healthy controls (n = 20, 85% female), implicating heightened sensitivity to facial emotion in BPD. Conversely, Domes et al. (2008) found that female BPD patients had detection thresholds comparable to a female non-clinical control group. BPD patients (N = 25) showed a significant reduction in detection threshold over the course of the experiment, compared to a control group (N = 25; matched on age, IQ and education), suggesting that enhanced sensitivity might be particular to emotional expression of familiar faces. Moreover, they found that BPD patients significantly over-reported anger when evaluating ambiguous blends of anger/ sadness and anger/happiness. Some of the differences in findings

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between the two studies might be explained by differences in experimental design. In Lynch et al.'s study, participants were allowed to change their mind as often as they liked during the course of the experiment, whereas in Domes et al.'s study the trial was stopped following the first response and participants were allowed to label the facial stimuli without the time restraints. Factors other than emotional sensitivity, such as the opportunity to guess, are thus likely to vary between the two studies. In summary, the majority of research to date does not support the assumption of general hypersensitivity to facial emotions in BPD. Rather, this collective evidence suggests more subtle impairments in labelling accuracy, as well as a tendency to interpret ambiguous faces in a more negative way (i.e., a bias toward negative emotional perceptions). It is also of note that females, whether girls or women, perform affect recognition tasks better than males (McClure, 2000; Thayer and Johnsen, 2000). The majority of studies reviewed in this paper have either used samples consisting entirely or mostly of females and thus reflect the predominance of the BPD diagnosis in females. Where mixed samples were used, the ratio of males to females was closely matched between clinical and control groups, suggesting that the observed pattern of results was not due to different gender ratios between clinical and control groups. Some of the differences in the findings could be accounted for by the choice of comparison group, as well as the choice of response format (free response vs. forced choice). More importantly, group differences in accuracy observed in the majority of previous studies do not necessarily reflect differences in sensitivity, as the majority have used facial stimuli at 100% expression without examining stimuli at lower levels of intensity. The use of dynamic emotional stimuli might be more appropriate, as they are more effective than static stimuli in activating brain areas that process emotion (LaBar et al., 2003; Sato et al., 2004). The abovementioned studies have recruited adult samples (mean age approximately 30 years or more). As BPD commonly has its onset in adolescence or early adulthood (Chanen et al., 2008a), the participants in the above studies are likely to have had long durations of illness. Therefore, previous research has been confounded by the effects of chronic BPD, as well as factors associated with the duration of illness, such as recurrent co-occuring Axis I disorders including substance use (Zanarini et al., 2004a), deliberate self-harm, cumulative traumatic events (Zanarini et al., 2005) and treatment (including polypharmacy) (Zanarini et al., 2004b). Examining the processing of social threat early in the course of BPD is likely to reduce the influence of such factors on brain morphology (Chanen et al., 2008b). However, comparing a younger BPD sample to adults with BPD (N30 yrs of age) may not be appropriate. This is because in younger participants brain development may not be complete in the key areas (e.g., frontal lobe) that are at least partially involved in recognising facial emotions (Adolphs et al., 2003; Toga et al., 2006). The present study therefore utilised a community control group in the same age range as the clinical participants. The aim of the present study was to explore the emotional sensitivity hypothesis in a sample of youth with features of BPD. If BPD is characterized by an underlying emotional sensitivity it would be expected that compared to healthy controls of the same age range, individuals with BPD features would show accurate identification of emotional expressions at earlier stages of expression across all presented emotional expressions. Moreover, it was hypothesised that in comparison to the community group of the same age range, the BPD group would have higher ratings of threat and arousal, as well as lower ratings of valence and dominance/ control of the ‘recognised’ facial expressions. 2. Method 2.1. Participants Twenty-one outpatients meeting three or more DSM-IV BPD criteria and aged between 15 and 24 years (mean age=18.90, SD=3.10 years; 3 male, 18 female) were recruited from the HYPE Clinic a specialized early intervention program for BPD (Chanen et al., 2009) at

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Orygen Youth Health, Melbourne, Australia. Participants were recruited within a month of their first contact with their assigned therapist at the clinic. Participants had never received specific treatment for BPD and were physically healthy, based upon medical history. Exclusion criteria for this group included: visual impairment (e.g., uncorrected vision or colour blindness); intellectual disability (as indicated in their clinical notes); a schizophrenia spectrum or affective psychotic disorder; intoxication with alcohol and/or any other licit or illicit drugs on the day of the procedure; or if they had a history of head injury, epilepsy, meningitis, encephalitis or a brain infection, loss of consciousness for 10 min or more, seizures, thyroid disorder or other significant medical illness. Twenty healthy controls aged between 16 and 24 years (mean age = 20.40, SD=2.72 years; 7 male, 13 female) were recruited from the local community through advertisements placed at public transport stops, libraries and community centres in the area. Additional exclusion criteria to the BPD criteria were applied to this group: no BPD or Antisocial PD features, and no history of psychiatric problems. 2.2. Measures All participants were screened for medical, neurological and sensory disorders, as well as demographic information, during a short phone interview. 2.2.1. Diagnostic measures for BPD participants Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I/P: (First et al., 1997b) was used to assess for psychotic, affective, anxiety, and eating disorders. For the purposes of this study, only the BPD and the Antisocial PD modules of the Diagnostic Interview for DSM-IV Personality Disorders (DIPD) were used. This is a reliable semi-structured interview designed to assess for DSM-IV Axis II disorders (Zanarini et al., 1996). In keeping with previous research, a personality disorder criterion was scored positive if it had been present for two (or more years) and did not occur exclusively during an Axis I disorder. 2.2.2. Screening measures for control participants The Structured Clinical Interview for DSM-IV Axis I Disorders Non-patient Edition (SCID-I/NP(First et al., 1996) was administered over the telephone to assess for the presence of Axis I disorders. Diagnostic modules of the SCID-I/NP are the same as those of the SCID-I/P (with the psychotic screen). The only differences between the SCID-I/P and the SCID-I/NP is the ‘overview’ section in the latter and that in the SCID-NP, there is no assumption of a chief complaint. The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD: (Zanarini et al., 2003) was used to screen for BPD symptoms in the community sample. The MSI-BPD is a 10-item yes/no questionnaire that is based upon the BPD module of the DIPD. It comprises one question for each of the first eight DSM-IV BPD criteria, and two questions for the ninth criterion (paranoia/dissociation). The MSI is one of the only instruments designed specifically for the screening of BPD and good psychometric properties have been reported in non-clinical samples (Zanarini et al., 2003). Screening for antisocial behaviour was conducted using the Structural Clinical Interview for DSM-IV Axis II Disorders Personality Questionnaire (SCID-II PQ: (First et al., 1997a). Only the 15 items corresponding to Criterion A (childhood conduct disorder) were used, as these items are necessary (but not sufficient) for a diagnosis of antisocial PD. 2.2.3. Facial emotion task The Face Morph Task was used to assess participants' ability to accurately assess participants' ability to perceive facial emotional expressions presented at varying degrees of intensity. This measure was based on the original task by Blair et al. (2001) utilising Ekman images (Ekman and Friesen, 1976) and modified for use in the present study at the Macquarie Centre for Cognitive Science. It was specifically designed to address the limitations of prior research while providing a more direct test of Linehan's (1993) hypothesis regarding the emotional sensitivity of individuals with BPD. The faces morph from neutral through to 100% expression of each of the six basic emotions (happy, sad, anger, fear, disgust and surprise) in five identities. The morphs were made using 5% intervals (using MorphX program), such that there were 25 images used in the progression from 0 (neutral)-100% (prototypic expression). The morphs were presented using DMDX 10 software, developed by Forster and Forster (http://www.u.arizona.edu/~kforster/dmastr/), on a laptop computer. A total of 30 morphed faces were presented in a randomised order, plus two practice trials. An example of the faces in the Face Morph task is presented in Fig. 1. Performance on the Facial Morph Task is measured in terms of sensitivity and impulsivity. Sensitivity was defined as the ability to recognise emotion at lower levels of intensity. Thus, the earliest correct responses for the six emotions were examined. Impulsivity was operationalized as the tendency to respond early and incorrectly to the task of identifying facial emotions. During the presentation of each morphed facial emotion sequence, participants were asked to press the space-bar button on the keyboard once they recognised the emotion shown on the face. The corresponding frame number (i.e., the threshold) was recorded for the point at which the facial expression was identified as ‘recognised’. The recognition accuracy was consequently measured using a forced-choice format: a) happy, b) sad, c) angry, d) fear, e) disgust and f) surprise. In addition, the participants were asked to rate their confidence, threat, valence, arousal and dominance/control of the ‘recognised’ facial expression on the scale 0–9. The following questions were asked to obtain the ratings: a) How confident are you about your choice of emotion? b) Please rate how HAPPY you feel about this face on the following scale?

c) Please rate how CALM you feel about this face on the following scale? d) Please rate how IN CONTROL you feel about this face on the following scale? e) Please rate how THREATENED you feel about this face on the following scale? 2.3. Procedure All procedures were approved by the Northwestern Mental Health Research and Ethics Committee, Melbourne, Australia. After complete description of the study procedure to potential participants, written informed consent was obtained from each participant and/or from a parent or guardian where appropriate. All tasks were completed in a quiet room at Orygen Youth Health. Participants were seated at a desk in front of the laptop computer, orientated to the purpose of the study and instructions of the task. They were encouraged to ask questions or directions if they felt the instructions were unclear prior to starting the task. Prior to commencing the experimental tasks, the DHQ was administered to all participants. Community participants also completed the screening measures for Axis I and II disorders. For the clinical participants, the diagnostic interview was completed as part of the routine entry assessment for the HYPE clinic. Clinicians are trained to a rigorous standard, using DSM-IV operational criteria, and this standard is maintained via a consensus diagnosis process for each patient, based upon a modified Longitudinal Expert All Data (LEAD) standard (Pilkonis et al., 1991). Inter-rater reliability is not routinely collected. Participants were remunerated AU$30 upon completion of the tasks. 2.4. Data analysis Two-way (2 × 6) repeated measures general linear models were conducted to determine group differences across the six emotion conditions in terms of sensitivity and impulsivity. Derived from these models were main effect for group, the main effect for emotion, as well as the interaction term. The interaction term was of interest for this study, as we wished to determine whether patterns of response to facial emotion expressions differed with respect to group membership. Independent samples t-tests were also used to examine differences on participants' ratings of their confidence, threat, valence, arousal and dominance of the ‘recognised’ facial expression. Due to the exploratory nature of the study, Cohen's d values (effect size) were calculated for each comparison. Cohen's (Cohen, 1992) guidelines for interpreting the magnitude of effect sizes (ES; small medium and large ESs are d = 0.20, 0.50, and 0.80 respectively) were used.

3. Results 3.1. Sample characteristics Key demographic variables for both groups are reported in Table 1. There were no significant differences between the groups on age and sex (all P N 0.05). There was a significantly higher proportion of tertiary educated students in the community group and lower proportion of participants born outside of the Australia/New Zealand region (all P b 0.05). All clinical participants had a co-morbid mood and/or anxiety disorder (57% MDE, 48% PTSD, 48% Panic Disorder, 33% Dysthymia, 24% GAD, 14% Social Phobia, 14% Bulimia, 10% Bipolar II, 10% Specific Phobia). The mean number of DSM-IV BPD criteria met was 5.10 (SD = 1.58), with 12 (57.1%) participants meeting the full threshold (5 or more criteria), 6 (29%) participants meeting 4 criteria and 3 (14%) participants meeting 3 criteria. Eleven (52%) participants were taking antidepressant medication, 2 (10%) were on mood stabilisers and 1 (5%) was on antipsychotic (atypical) medication. 3.2. Sensitivity and impulsivity to facial affect 3.2.1. Differences in earliest frame for correct response — “Sensitivity” Two participants from the community group incorrectly identified ‘disgust’ across all 5 identities and were therefore excluded from this analysis. The interaction term (Group × Emotion) from the two-way general linear model was not significant (P N 0.05). There was a significant main effect for Emotion, F(5, 185) = 25.611, p b 0.001, partial ŋ2 = 0.41; but not for Group (P N 0.05). There was an overall difference in earliest response to different types of emotions. In particular, ‘happy’ emotion was identified earlier and ‘angry’ emotion was identified later in comparison to the other five emotions (all P b 0.05).

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Fig. 1. Example of morphed angry face at 0, 20, 40, 60, 80 and 100% intervals.

Table 2 shows that the ESs were mostly in the small range (Cohen's d 0.0–0.4), except for ‘fear’ and ‘disgust’ which were in the moderate ES range (Cohen, 1992), thus suggesting that the BPD group was somewhat slower at correctly identifying these two emotions. 3.2.2. Differences in earliest incorrect response — “Impulsivity” Since only 7 participants identified all 6 emotions incorrectly, it was not appropriate to conduct repeated measures ANOVA on the incorrect responses data. Instead, between-group comparisons were conducted to examine differences between groups on earliest incorrect response to specific emotions across the six emotions (see

Table 1 Demographic characteristics for the BPD and community groups.

Age (mean ± SD years) Sex (N(%) female) Accommodation (N (%)) Alone Family/partner/friends Other Country of birth (N (%)) Australia/NZ Employment (%) Student Employed Unemployed Education (%) Tertiary Secondary Lower-secondary

BPD

Community

Χ2

P

18.90 ± 3.10 18 (86)

20.40 ± 2.72 13 (65)

t = −1.64 2.38

0.12 0.12

0 17 (81) 4 (19)

1 (5) 81 (95) 0

4.01

0.14

20 (95)

13 (68)

4.97

0.02a

11 (53) 7 (33) 3 (14)

14 (74) 4 (21) 1 (5)

2.08

0.35

0 13 (62) 8 (38)

7 (37) 12 (63) 0

14.98

0.001b

2

Note: N = 19 in community group for all Χ analysis except ‘Sex’ due to missing data. a Significant at alpha = 0.05 level. b Significant at alpha = 0.01 level.

Table 2). There were no significant differences (all P N 0.05) between the groups. The ESs were mostly in the small range (Cohen's d 0.0–0.4), except for ‘happiness’ which was in the moderate ES range (Cohen, 1992), thus suggesting the BPD group might be impulsive (respond earlier with errors) in identifying ‘happiness’ than the community control group. 3.3. Confidence, threat, valence, arousal and dominance ratings Planned between-group comparisons were conducted to examine differences between BPD and control groups on self-rated levels of confidence, threat, subjective valence, arousal, and dominance/control, in response to each facial expression (see Table 3). Although there were no significant group differences for any of these subjective responses (all P N 0.05), moderate effect sizes were observed for subjective valance ratings, with the BPD group rating ‘disgust’ and ‘happy’ emotions as less positive compared to the community group (Cohen's d 0.5 to 0.6). Moreover, the BPD group rated reduced feelings of control in response to ‘anger’, ‘disgust’, ‘happy’ and ‘sad’ emotions compared to the community group (Cohen's d 0.5 to 0.6). 4. Discussion The present study found no evidence of heightened sensitivity (operationalized as the ability to detect emotions at lower thresholds of expressivity) for emotional facial expressions in a sample of young people with features of BPD. Both groups showed similar accuracy in recognising emotional expressions. The findings of the present study are consistent with those of Domes et al. (2008) who reported an emotion detection threshold in BPD participants comparable to the non-clinical control group. Conversely, Lynch et al. (2006) reported a generally heightened sensitivity for recognition of facial emotions in

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Table 2 Means, standard deviations and effect sizes for the BPD and community groups on earliest correct and incorrect response to specific emotions. Earliest correct response BPD

Anger Disgust Fear Happiness Sadness Surprise

Earliest incorrect response Community

BPD

Community

Mean

SD

Mean

SD

Cohen's d

Mean

SD

Mean

SD

Cohen's d

34.30 29.36 29.63 21.40 29.63 25.51

8.04 4.40 7.49 6.95 7.02 5.41

31.47 25.68 26.50 19.79 27.76 24.65

8.24 7.61 5.58 5.39 7.67 7.58

0.4 0.6 0.5 0.3 0.3 0.1

27.77 25.10 27.65 14.33 27.94 24.33

10.09 7.38 11.85 15.95 13.50 11.57

29.98 28.10 25.09 19.86 30.00 24.21

14.58 13.19 12.60 7.99 8.12 8.24

-0.2 0.3 0.2 -0.5 0.2 0

Bold — moderate effect size.

BPD. Methodological differences between studies might explain these discrepancies. In Lynch et al.'s (2006) study, participants could change their responses as often as they liked during the course of each trial. In both the present study and that of Domes et al. (2008), each trial was stopped following the first response and the recorded response could not be altered. Therefore, factors other than emotional sensitivity, such as the propensity to engage in subsequent guessing, might account for these inconsistencies. The present study also suggests that the BPD group rated ‘disgust’ and ‘happiness’ as less positive than the community group (effect sizes range 0.5 to 0.6), which is consistent

Table 3 Difference between groups on ratings of confidence, threat, valence, arousal and dominance. BPD

Community

Mean

SD

Mean

SD

t

P

Cohen's d

Confidence Anger Disgust Fear Happiness Sadness Surprise

6.25 6.51 6.67 7.15 6.64 6.11

2.21 2.21 1.88 1.89 2.40 2.00

6.43 6.93 6.87 6.98 6.91 6.80

1.50 1.22 1.00 1.41 1.44 1.62

− 0.312 − 0.732 − 0.414 0.334 − 0.437 − 1.201

0.76 0.47 0.68 0.74 0.66 0.24

− 0.1 − 0.2 − 0.1 0.1 − 0.1 − 0.4

Threat Anger Disgust Fear Happiness Sadness Surprise

3.53 3.72 2.80 2.30 2.71 2.20

2.91 3.15 2.31 1.96 2.68 1.95

3.21 3.03 2.77 1.59 2.32 2.44

2.43 2.47 2.33 1.79 2.02 1.94

0.38 0.78 0.04 1.21 0.53 0.38

0.71 0.44 0.97 0.23 0.60 0.71

0.1 0.3 0.0 0.4 0.2 0.1

Valance Anger Disgust Fear Happiness Sadness Surprise

3.19 3.14 4.05 4.72 3.38 4.10

2.34 2.10 2.14 2.44 2.21 2.28

3.96 4.03 4.10 5.98 3.99 4.84

1.20 1.47 1.20 1.63 1.23 1.15

− 1.31 − 1.56 − 0.10 − 1.92 − 1.08 − 1.29

0.20 0.13 0.92 0.06 0.29 0.21

− 0.4 − 0.5 0.0 − 0.6 − 0.3 − 0.4

Arousal Anger Disgust Fear Happiness Sadness Surprise

2.48 2.70 2.71 2.33 1.99 2.25

2.89 2.68 2.66 2.37 2.18 2.27

2.53 2.36 2.56 2.66 2.62 2.66

2.38 2.44 2.45 2.54 2.51 2.30

− 0.07 0.42 0.19 − 0.43 − 0.86 − 0.58

0.95 0.68 0.85 0.67 0.40 0.57

0.0 0.1 0.1 − 0.1 − 0.3 − 0.2

Dominance/control Anger 4.18 Disgust 4.10 Fear 5.01 Happiness 4.66 Sadness 4.63 Surprise 4.93

3.02 2.86 3.19 3.17 2.96 3.08

5.41 5.51 5.41 6.28 5.86 5.74

2.33 2.44 2.20 2.14 2.42 2.32

− 1.45 − 1.70 − 0.47 − 1.92 − 1.45 − 0.95

0.15 0.10 0.64 0.06 0.15 0.35

− 0.5 − 0.5 − 0.1 − 0.6 − 0.5 − 0.3

Bold — moderate effect size.

with Meyer et al.'s (2004) study showing that BPD features in healthy students are associated with negative bias in appraising social cues. If BPD is characterised by an underlying emotional sensitivity (Linehan, 1993), individuals with BPD features should demonstrate correct recognition of emotions at lower threshold levels regardless of emotional valence. However, the present sample of youth with BPD features showed recognition response latencies similar to the community group, with somewhat longer latencies for the recognition of fear and disgust (effect sizes of 0.5 to 0.6, respectively). Although it appears that the participants in the control group are somewhat older than the clinical sample, it is unlikely that this influenced the pattern of results as both groups are in the same age range (15 to 24 years) and therefore in the similar stage of development in the key brain areas (e.g., frontal lobe) that are at least partially involved in recognising facial emotions (Adolphs et al., 2003; Toga et al., 2006). While these findings appear to be inconsistent with the theoretical prediction that emotion dysregulation in BPD is associated with emotional sensitivity (Linehan, 1993), the findings from this sample of young individuals with BPD features might also be taken to suggest that emotional sensitivity is present only in severe BPD or develops later in the course of the disorder, perhaps through continuing exposure to traumatic life events and recurrent mental state disorders (Jovev and Jackson, 2006). Recurrent or chronic Axis I disorders (notably mood and substance use disorders) and cumulative traumatic life events might lead to changes in cognition, emotion, behaviour or biology (Lewinsohn et al., 1981; Shea et al., 1996; Ormel et al., 2004; Beevers et al., 2007) and render individuals vulnerable to developing cognitive biases, such as increased emotional sensitivity, later in the course of the disorder. The BPD sample in this study was specifically chosen to minimise ‘duration of illness’ factors and is different in several regards to the ‘late-stage’ BPD syndrome described in the DSM-IV-TR (APA, 2000) and typically seen in adult mental health settings. Participants in this study were youth with both sub-syndromal and full-syndrome BPD who were, on average, younger than participants in comparable studies of adult BPD. Nevertheless, diagnosing adolescent personality pathology remains controversial (Chanen and McCutcheon, 2008) but has been shown to be as reliable and valid in adolescence as it is in adulthood (Chanen et al., 2008a; Miller et al., 2008). Moreover, it is widely acknowledged that personality disorders are best conceptualised as dimensional constructs (Clark, 2007) and that BPD exists on a continuum of clinical severity, with no distinct boundary between sub-syndromal and threshold BPD (Johansen et al., 2004). One limitation of the present study relates to the specificity of our findings to BPD. Comorbidity is typical of BPD samples at any age (Chanen et al., 2007) and future studies should employ a clinical comparison group. Similar to Domes et al. (2008), there were high rates of PTSD (48%) in the present sample and although the healthy comparison group were screened for the absence of PTSD, we did not assess them for histories of childhood abuse or neglect. An exploratory three-group analysis (BPD vs. BPD + PTSD vs. community control)

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indicated that the BPD group with no PTSD diagnosis was slower at recognising happiness than the other two groups (ES = 0.5). Larger studies that can include comparison groups of individuals with comorbid PTSD, depression, other personality disorders, and/or no other personality pathology would afford the ability to disentangle the effects of Axis I anxiety and depressive disorders as opposed to personality pathology on emotion sensitivity. Another limitation of this study related to the high level of education in the healthy control group, which might limit generalizability. Although every effort was made to advertise study participation in the wider community, the geographical area that is covered by the clinical service incorporates several universities that led to the high number of tertiary-educated individuals volunteering to participate in the study. Future research should strive to better match the participants in this domain. It is also of note that females perform affect recognition tasks better than males (McClure, 2000; Thayer and Johnsen, 2000) and the clinical group in the present study had somewhat more females than the community group (although not significant due to the small sample size). It is therefore possible that the mixing of sexes obscured group differences; however, repeating the analyses only for the female participants did not alter the general pattern of the results. Females with BPD features showed recognition response latencies similar to the community females, with somewhat longer latencies for the recognition of fear and disgust and effect sizes similar to the entire sample (0.4 to 0.6, respectively). Moreover, if BPD is characterised by an underlying emotional sensitivity (Linehan, 1993) and females are more sensitive to affect than males, the clinical group in the present study (with more females and more BPD features) should demonstrate shorter latencies for correctly recognised emotions. The findings of the present study suggest similar response latencies between the two groups, and where the differences might be present (fear and disgust) these are in the opposite direction to the pattern expected for emotional sensitivity. Moreover, there are some general limitations that need to be acknowledged when using both static and dynamic affect recognition paradigms. Most of these studies use faces unfamiliar to the participants, and do not examine social interactions or social context effects. The exploration of these factors in experimental settings may inform issues regarding therapeutic alliance and psychosocial functioning in everyday social situations. Despite these limitations, this is the first study to explore emotional sensitivity using dynamic facial expressions in youth early in the course of BPD. This allowed us to minimise duration of illness effects, although less severe levels of BPD pathology might have also resulted in moderate effect sizes observed in this study. Although our sample size is relatively small to detect the moderate effect sizes, it is comparable to the sample sizes used in the studies by Lynch et al. (2006) and Domes et al. (2008). Further research is needed to replicate these findings in a larger sample. In addition, we used validated diagnostic measures to determining study eligibility, thus representing more stringent inclusion criteria than previous studies of BPD. In summary, outpatient youth with BPD features did not show evidence of heightened sensitivity to emotional facial expressions. They were accurate in recognising emotional expressions. These findings suggest that emotional sensitivity might be a core feature of severe BPD only, or it might develop later in the course of the disorder. Further research is needed to examine emotional reactivity and sensitivity across various phases of the disorder in larger clinical samples.

Acknowledgements The face morph task was modified for use by Dr Tim Bates at Macquarie Centre for Cognitive Science, Macquarie University, Sydney, Australia. This project was supported by a 2007 Early Career Grant awarded by the University of Melbourne to the first author.

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