- Email: [email protected]
Experimental investigation of cognitive and affective empathy in borderline personality disorder: Effects of ambiguity in multimodal social information processing
Psychiatry Research 253 (2017) 58–63
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Experimental investigation of cognitive and affective empathy in borderline personality disorder: Effects of ambiguity in multimodal social information processing
MARK
⁎
Inga Niedtfeld
Department of Psychosomatic Medicine, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim / Heidelberg University, Germany
A R T I C L E I N F O
A BS T RAC T
Keywords: Borderline Personality Disorder Empathy Emotional intelligence Facial expressions Nonverbal Communication
Borderline personality disorder (BPD) is characterized by affective instability and interpersonal problems. In the context of social interaction, impairments in empathy are proposed to result in inadequate social behavior. In contrast to findings of reduced cognitive empathy, some authors suggested enhanced emotional empathy in BPD. It was investigated whether ambiguity leads to decreased cognitive or emotional empathy in BPD. Thirtyfour patients with BPD and thirty-two healthy controls were presented with video clips, which were presented through prosody, facial expression, and speech content. Experimental conditions were designed to induce ambiguity by presenting neutral valence in one of these communication channels. Subjects were asked to indicate the actors’ emotional valence, their decision confidence, and their own emotional state. BPD patients showed increased emotional empathy when neutral stories comprised nonverbally expressed emotions. In contrast, when all channels were emotional, patients showed lower emotional empathy than healthy controls. Regarding cognitive empathy, there were no significant differences between BPD patients and healthy control subjects in recognition accuracy, but reduced decision confidence in BPD. These results suggest that patients with BPD show altered emotional empathy, experiencing higher rates of emotional contagion when emotions are expressed nonverbally. The latter may contribute to misunderstandings and inadequate social behavior.
1. Introduction Borderline Personality Disorder (BPD) is characterized by a pervasive pattern of instability in emotion regulation, self-image, impulse control, and interpersonal relationships (APA, 2013). One of the most stable and debilitating symptoms in BPD are difficulties in interpersonal relationships (Gunderson, 2007; Gunderson et al., 2011). In the course of interpersonal conflict, patients are also more likely to show emotional hyperactivity and emotion dysregulation (Gunderson and Lyons-Ruth, 2008; Hepp et al., 2017), and show dysfunctional behaviors such as suicide attempts or non-suicidal self-injurious behavior (Brodsky et al., 2006; Welch and Linehan, 2002). In search of factors possibly causing interpersonal problems in BPD, previous research has pointed, among other factors, to difficulties in emotion recognition and empathy (for an overview, see (Lazarus et al., 2014)). Empathy, the ability to understand and experience the thoughts and emotions of interaction partners (Davis, 1983; Eisenberg and Miller, 1987), is crucial for successful social interaction. Two facets,
cognitive and affective empathy, are commonly distinguished (Davis et al., 1987). Cognitive empathy describes the ability to cognitively understand the perspective, reactions, and emotions of others. Overlapping constructs are mentalization and theory of mind. Closely related to cognitive empathy, emotion recognition is the ability to accurately determine the emotional states of others from their emotional expression (Ekman and Friesen, 1971). Affective empathy is conceptualized as emotional responding, which is congruent with the emotion of an interaction partner (Davis et al., 1987). Moreover, as a precursor of affective empathy, emotional contagion was described as an automated mirroring of the emotional reaction of another person (Hatfield et al., 1994), also present in babies and animals (Singer and Klimecki, 2014). Affective empathy is a less studied field in BPD than cognitive empathy (Dinsdale and Crespi, 2013; Roepke et al., 2012). 1.1. Self-reported empathy in BPD Five studies investigated affective and cognitive empathy using a
⁎ Correspondence address. Central Institute of Mental Health, University of Heidelberg, Department of Psychosomatic Medicine and Psychotherapy, PO Box 12 21 20, 68072 Mannheim, Germany. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.psychres.2017.03.037 Received 12 October 2016; Received in revised form 13 March 2017; Accepted 20 March 2017 Available online 23 March 2017 0165-1781/ © 2017 Elsevier B.V. All rights reserved.
Psychiatry Research 253 (2017) 58–63
I. Niedtfeld
empathy test (Dziobek et al., 2008), showing pictures of complex social situations to investigate cognitive and emotional empathy (“How much do you feel for the person?”). The first study reports deficits in this measure of affective empathy in BPD (Dziobek et al., 2011), the second does not find significant differences between BPD patients ad healthy controls (Wingenfeld et al., 2014). The third study assessed facial electromyography during a facial recognition task. The authors hypothesized that BPD patients show increased facial mimicry, which could be interpreted as a basal form of empathy (Matzke et al., 2014). However, the results of the study point to a general tendency in BPD to react with augmented activation of the corrugator supercilii muscle (i.e. frowning) to all displays of negative expressions. The authors interpreted this finding as evidence for a negativity bias, but not for heightened affective empathy in BPD.
self-report measure, the Interpersonal Reactivity Index (IRI; (Davis, 1983)). The first study found self-reported affective empathy on both IRI subscales (empathic concern and personal distress) to be higher in BPD than in nonclinical controls, whereas self-reports of cognitive empathy (i.e., the subscale perspective taking) was lower in the BPD group (Guttman and Laporte, 2000). Three other studies using the IRI also reported lower cognitive empathy with regard to the IRI subscale perspective taking (Dziobek et al., 2011; Harari et al., 2010; New et al., 2012). However, regarding affective empathy, findings are less clear: Three of the four studies found higher values on the subscale personal distress, but no significant effects for self-reported empathic concern (Dziobek et al., 2011; Matzke et al., 2014; New et al., 2012). Higher values in personal distress in BPD might result from heightened emotional contagion (Hatfield et al., 1993; Herpertz and Bertsch, 2014), while empathic concern was described as a more mature form of empathy (Singer and Klimecki, 2014), leading to emotions like compassion. However, one study did not find any significant differences between BPD patients and healthy controls with regard to affective empathy (Harari et al., 2010). Finally, a recent study found affective empathy to be higher in female adolescents with BPD than in psychiatric control patients (Kalpakci et al., 2016). Notably, the authors used the Basic Empathy Scale for self-reported emotional empathy (Jolliffe and Farrington, 2006), explicitly assessing congruent affective reactions.
1.4. The current study The current study was designed to investigate cognitive and affective empathy in BPD using multimodal stimuli with high ecological validity. Additionally, it is aimed at a deeper understanding of the influence of ambiguity on cognitive and emotional empathy in BPD. In contrast to our previous study (Niedtfeld et al., 2016), which investigated the recognition of isolated information channels (text only, video without audio, and audio only) as compared to videos (all channels containing the same emotion), in this study we focused on the impact of ambiguity between information channels. In daily life, communication is not always as clear as in the laboratory. There is evidence that inconsistencies between verbal and nonverbal information result in a larger influence of nonverbal cues on emotion ratings (Argyle et al., 1971; Jacob et al., 2012). A study in healthy controls found that inconsistencies between verbal and nonverbal information decrease emotion recognition and affective empathy differentially, dependent on the affected communication channel (Regenbogen et al., 2012a). A recent study on emotion recognition in BPD demonstrated that patients relied more on nonverbal cues when verbal and nonverbal signals were contradictory (Bruck et al., 2016). Since previous research suggests impairments in cognitive empathy in BPD, it was hypothesized that (1) BPD patients would show lower performance in emotion recognition than HC, and (2) this emotion recognition deficit would be most pronounced when stimuli are ambiguous. Furthermore, BPD patients were expected (3) to experience lower confidence with regard to the emotion recognition task. Finally, it was hypothesized that (4) those with BPD show altered affective empathy (i.e. experience of the same emotion as their interaction partner) as compared to healthy controls.
1.2. Behavioral measures of cognitive empathy in BPD A relatively large body of studies investigated emotion recognition abilities in BPD patients. Most of the studies asked patients with BPD and healthy controls (HC) to categorize an emotional expression from a picture or photograph. Two meta-analyses in BPD found reduced emotion categorization abilities (Daros et al., 2013; Mitchell et al., 2014). The authors conclude that patients more often rated neutral faces as negative emotional, and had difficulties with the detection of anger and disgust. However, one could argue that studies using images of facial expressions are lacking ecological validity, because social cognition is likely to rely on multimodal and dynamic stimuli. During everyday communication, cues from different communication channels have to be integrated, such as facial expressions, speech content, and prosody (Regenbogen et al., 2012a). Only a few studies used film clips to study emotion categorization in BPD (Baez et al., 2015; Preissler et al., 2010) and in adolescents with high versus low borderline traits (Sharp et al., 2011), confirming impairments in the recognition of emotions. A study by Minzenberg et al. (2006) found impaired ability for emotion recognition only with integrated audiovisual stimuli, but not with isolated visual or auditory stimuli. A recent study from our own group tested whether difficulties in emotion recognition in BPD are based on deficits in the recognition of isolated social cues (Niedtfeld et al., 2016), and showed reduced emotion recognition abilities in BPD whenever facial expressions were presented. In addition to emotion recognition abilities, confidence in emotion judgements was investigated in four studies, asking how confident subjects were with regard to their decisions. Two studies (Kaletsch et al., 2014; Thome et al., 2016) reported lower confidence in ratings of emotion intensity in BPD, the first with regard to the emotional valence of body movements, the second with regard to facial expressions. One study showed enhanced confidence in BPD (Schilling et al., 2012), using the reading the mind in the eyes test. A recent study using dynamic stimuli of facial expressions found no difference with regard to confidence ratings between BPD and HC (Lowyck et al., 2016).
2. Methods 2.1. Participants Thirty-five unmedicated women diagnosed with BPD according to the DSM-IV (APA, 2013) and 32 healthy women were invited to participate in the study. Healthy subjects were recruited by newspaper advertisement, patients at the Department of Psychosomatic Medicine, Central Institute of Mental Health (CIMH) in Mannheim, Germany. Trained clinicians assessed BPD diagnosis and axis I comorbidities with the German version of the Structural Clinical Interview for DSMIV Axis-I (Wittchen et al., 1997) and Axis-II (Fydrich et al., 1997). Healthy subjects did not fulfil criteria of any axis I or II disorder. Exclusion criteria for patients were current substance abuse, bipolar disorder, schizophrenia, and a current severe depressive episode. One patient had to be excluded due to the disclosure of substance dependency after participation. Further assessments included self-ratings of BPD symptoms with the Borderline Symptom List-23 (BSL-23) (Bohus et al., 2009), current mood with the Positive and Negative Affect Schedule (PANAS) (Watson
1.3. Behavioral measures of affective empathy in BPD There are three studies assessing facets of affective empathy at the behavioral level in BPD (Dziobek et al., 2011; Matzke et al., 2014; Wingenfeld et al., 2014). Two of these studies used the multifaceted 59
Psychiatry Research 253 (2017) 58–63
I. Niedtfeld
sure). Finally, they had to indicate their own current emotion (disgusted, fearful, happy, sad, or neutral) as a measure for emotional empathy. They responded with three response buttons (skip left, skip right, enter). During the inter-trial-interval (~ 4.53 s), a white fixation cross on black background was shown. Skin conductance was recorded as a measure of sympathetic arousal during the experiment, but data will not be reported here.
Table 1 Main clinical data and self-report data of the sample. BPD (n=34)
Demographics Age (years) Education (years) Questionnaires BSL−23 DSS-Acute PANAS positive PANAS negative
HC (n=32)
Mean
SD
Mean
SD
p
28.26 11.41
8.11 1.64
31.16 11.48
8.47 1.61
0.16 0.86
1.93 2.02 2.32 1.87
0.72 0.93 0.50 0.53
0.16 1.06 2.93 1.07
0.19 0.15 0.71 0.09
< 0.001 < 0.001 < 0.001 < 0.001
2.3. Statistical analyses
et al., 1988), and dissociative symptoms with the Dissociation Tension Scale acute (DSS-acute) (Stiglmayr et al., 2010). The DSS-acute is a self-rating instrument, consisting of 21 items assessing psychological (e.g., derealization, depersonalization, amnesia) and somatic dissociation (e.g., perception of pain, vision and hearing). Participants gave written informed consent after they received a full description of the study protocol. The study was approved by the ethics committee of the Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg. The final sample consisted of 34 patients with BPD and 32 healthy controls, which did not differ in years of education (t(63) = 0.179; p=0.86) or age (t(64) = 1.416; p=0.16), see Table 1 for more details on demographics and self-report measures. Borderline patients had on average 1.94 current comorbid Axis I diagnoses, which included current depressive disorders (n=20); anxiety disorders (n=12); posttraumatic stress disorder (15); somatoform disorders (n=1); eating disorders (n=6); substance use, but abstinent for at least 2 months (n=5); substance dependency lifetime, but abstinent for at least one year (n=5); and attention deficit hyperactivity disorder (n =2).
To test the four hypotheses, a repeated measure analyses of variance (rmANOVA) was calculated, entering group (BPD vs. HC) as between-subjects factor, experimental condition (all emotional, neutral face, neutral prosody, and neutral speech content) as within-subjects factor, and the respective dependent variable (percentage accuracy scores, mean confidence ratings, percentage of empathic reactions). Emotional valence (disgusted, fearful, happy, sad, or neutral) was not introduced as an additional within-subjects factor for two reasons. First, this would have led to an unbalanced factorial design, since neutral valence is only feasible within the condition all emotional. Additionally, the number of observations within the cells of a 2×4×5factorial design would be n=4, leading to violation of the assumptions of variance homogeneity and normality of the distribution. Means and standard deviations for each valence within each experimental condition are presented in Supplemental Tables 1 and 2. Level of significance was set to p < 0.05. If Mauchly's test of sphericity was significant (p < 0.05), Greenhouse–Geisser correction was applied. For post-hoc group comparisons within experimental conditions, corrected degrees of freedom are reported in case of unequal variances (as indicated by Levene's test). To correct for multiple comparisons, the Holm-Bonferroni procedure was applied. For each experimental condition, effect size Cohens d was computed between BPD and HC. According to Cohen (1988), an effect size of d =0.2 reflects a small effect, d = 0.5 a medium and d =0.8 a large effect size.
2.2. Stimulus material & procedure
3. Results
The stimulus material was developed by Regenbogen et al. (2012a), and was previously applied in healthy participants (Regenbogen et al., 2013, 2012b), patients with autism spectrum disorder (Schneider et al., 2013), and patients with depression (Schneider et al., 2012). Each trial consisted of a short video clip (~12 s) showing a person telling a selfrelated story with different emotional valence (disgust, fear, joy, sadness, neutral). The experimental conditions were designed to induce ambiguity by setting the emotionality of one communication channel (speech content, facial expression, prosody) to neutral. In the condition all emotional, a person tells a self-relevant emotional story with corresponding prosody and emotional facial expression. In the conditions neutral face, neutral prosody, and neutral speech content, the respective channel incorporates a neutral valence, while the two remaining channels comprise the target emotion. For example, in the condition neutral speech content, a person says: “Last night I cleaned up the pantry. Then I went to brush my teeth in the bathroom. I watched TV for a short time and went to bed”. At the same time, her facial expression and prosody point to fear. After participants gave informed consent, filled out the questionnaires and received the task instruction, they completed three practice trials. Within every trial of the experiment, subjects were presented with a random sequence of 80 video stimuli (16 trials per experimental condition and per valence), showing 12 different persons. Every video was unique with regard to the content and was shown only once. After every video, subjects were asked to label the presented emotion with one out of five choices (disgusted, fearful, happy, sad, and neutral) without any time limit. Afterwards, they indicated how confident they were in their decision on a 6–point-likert-scale (1= very unsure, 6=very
3.1. Cognitive empathy
BPD: Borderline Personality Disorder; HC: Healthy Control Subjects; BSL-23: Borderline Symptom List (general score); PANAS: Positive and negative affect schedule, subscales positive and negative affect; DSS-Acute: Dissociation Tension Scale.
As dependent variable, percentage accuracy scores for the emotion recognition task were calculated for every experimental condition (all emotional, neutral face, neutral prosody, and neutral speech content) across all emotions. A repeated measure analysis of variance (rmANOVA) was calculated with group (BPD vs. HC) as betweensubjects factor, experimental condition as within-subjects factor, and the percentage accuracy score as dependent variable. Results showed a significant main effect for condition (F(1.68,107.33) = 41.552, p < 0.001, ηp2 = 0.40). Post-hoc pairwise comparisons exploring the main effect of condition pointed to significant different percentage accuracy scores between every condition (all emotional > neutral prosody > neutral face > neutral speech content, all p < 0.001). We did not observe a significant main effect for group (F(1, 64) = 0.118, p=0.37 (one-sided), ηp2 =0.002) or interaction effect (F(1.68,107.33) =1.861,p = 0.138, ηp2 =0.03). In conclusion, the first and second hypotheses regarding impaired emotion recognition in BPD were not confirmed. Table 2 provides means, standard deviations, and the effect size Cohens d for correct emotion recognition. The confidence of the subjects in their emotion recognition decision was analyzed with rmANOVA, again entering group (BPD vs. HC) and experimental condition as independent variables, and the mean confidence rating as dependent variable. Results showed a significant main effect for condition (F(2.139,136.923) = 56.987, p < 0.001, ηp2 = 0.47), and a significant main effect for group (F(1, 64) = 2.968, p < 0.05 (onesided), ηp2 = 0.04), but no significant interaction effect for group×condition (F(2.139,136.923) = 0.063, p = 0.95, ηp2 = 0.001). In every 60
Psychiatry Research 253 (2017) 58–63
I. Niedtfeld
Table 2 Means, standard deviations and effect sizes for the accuracy scores in percent. The respective rmANOVA resulted in a significant main effect of condition, but no significant effects for group or group by condition interaction. Condition
All emotional neutral content Neutral face Neutral prosody
BPD (n =34)
HC (n =32)
Mean
SD
Mean
SD
HC > BPD
95.50 81.80 73.16 88.97
5.72 16.88 18.81 9.86
96.29 83.79 65.23 91.41
3.68 13.27 27.63 8.21
0.17 0.13 −0.34 0.27
Table 4 Means, standard deviations and effect sizes for empathic reactions in percent. The respective rmANOVA resulted in significant results for the main effect condition and the group by condition interaction.
effect size d
Condition
all emotional neutral content neutral face neutral prosody *
All emotional Neutral content Neutral face Neutral prosody
BPD (n=34)
HC (n=32)
Effect size d
Mean
SD
Mean
SD
HC > BPD
4.23 4.61
0.97 1.04 1.03 0.94
5.24 4.26 4.53 4.98
0.61 0.82 0.86 0.73
0.41 0.36 0.32 0.44
HC (n=32)
effect size d
Mean
SD
Mean
SD
HC > BPD
75.09 36.76 45.22 55.70
14.13 29.98 26.34 28.34
85.84 20.31 55.47 66.41
13.07 22.78 27.94 25.09
0.79* −0.62* 0.38 0.40
=p < 0.05, Post-Hoc T-tests, Holm-Bonferroni corrected.
Subsequently, follow-up exploratory analyses were calculated in order to test whether the emotional valence had an effect within the significant experimental conditions. To correct for multiple comparisons, the Holm-Bonferroni procedure was applied. For the condition all emotional, where BPD patients showed reduced emotional empathy, Post hoc t - tests of emotional empathy for each emotional valence (neutral, happy, sad, fear, disgust) were calculated. BPD patients descriptively showed reduced emotional empathy in response to every emotional valence, and differed significantly from HC when the condition all emotional included neutral (t(50.276)=3.363, p < 0.05 (Holm-Bonferroni corrected), d=0.85) emotional valence. For the experimental condition with neutral content, post hoc t - tests of emotional empathy were calculated for each presented emotional valence (happy, sad, fear, disgust). Again, BPD patients descriptively showed increased emotional empathy with regard to every emotional valence, and differences to HC were significant when sadness (t(59.676) = 2.701, p < 0.05 (Holm-Bonferroni corrected), d = 0.67) or fear (t(57.231) = 2.560, p < 0.05 (Holm-Bonferroni corrected), d = 0.64) were displayed in facial expression and prosody, although the speech content was neutral.
Table 3 Means, standard deviations and effect sizes for confidence (1= very unsure, 6=very sure) during emotion recognition task. The respective rmANOVA resulted in a significant main effect of condition and group, but no significant group by condition interaction. Condition
BPD (n=34)
experimental condition, patients were less confident regarding their emotion recognition than HC, confirming the third hypothesis (see Table 3).
3.2. Affective empathy With regard to the third hypothesis related to empathic reactions, another rmANOVA was conducted with group and experimental condition as independent variables, and the percentage of empathic reactions (i.e. own reported emotion = target emotion) as dependent variable. Results showed a significant main effect for condition (F(2.075,132.802) =119.346, p < 0.001, ηp2 = 0.65), but no significant main effect for group (F(1, 64) = 0.607, p = 0.439, ηp2 = 0.009). A significant group by condition interaction effect (F(2.075,132.802) =11.62, p < 0.001, ηp2 = 0.15) was observed. Post hoc t - tests revealed reduced affective empathy in BPD in the condition all emotional (t(64) = 3.202, p < 0.01 (Holm-Bonferroni corrected), d=0.79), and enhanced affective empathy in the condition neutral content (t(61.337) = 2.519, p < 0.05 (Holm-Bonferroni corrected), d=0.62). Therefore, the third hypothesis regarding altered affective empathy in BPD was confirmed. The results on affective empathy are depicted in Fig. 1. Table 4 provides means, standard deviations, and effect sizes for empathic reactions.
4. Discussion In this study, cognitive and affective empathy in BPD were investigated, using ecologically valid video stimulus material. During the task, subjects rated emotions in short video clips that provided emotional information via three different channels: Speech content, prosody and facial expression. In order to investigate the effect of decreased clarity or ambiguity, experimental manipulation involved conditions where each of these information channels was set to neutral. Cognitive empathy was tested with a classical forced-choice emotion recognition task. There was no evidence for impaired emotion recognition abilities in BPD compared to HC. This is in line with some previous studies reporting on emotion recognition of full emotional facial expressions in BPD vs HC (Domes et al., 2008; Dyck et al., 2009; Lynch et al., 2006; Mier et al., 2013; Robin et al., 2012; v CeumernLindenstjerna et al., 2007; Wagner and Linehan, 1999), but not in line with studies that used complex stimulus material like video clips to investigate cognitive empathy (Dziobek et al., 2011; Niedtfeld et al., 2016; Preissler et al., 2010). One explanation could be that there was no time limit for the decision process (Dyck et al., 2009). Comparing the condition all emotional between our first study (Niedtfeld et al., 2016) and the present study, the mean values of correct emotion recognition was comparable in BPD patients (94.29% versus 95.50%) and healthy control subjects (97.23% versus 96.29%). However, low differences with regard to the other experimental conditions in the present study resulted in a nonsignificant group by condition interaction effect. Based on the overall high rates of correct emotion recognition in the current study, one can assume that the current task had a low difficulty, which consequently may have caused a ceiling effect. Only in the experimental condition with neutral facial expression, accuracy scores were lower than 80% in both groups.
Fig. 1. Empathic reactions in Patients with BPD (grey bars) and HC (white bars), dependent on the experimental condition. *=p < 0.05, Post-Hoc T-tests, HolmBonferroni corrected.
61
Psychiatry Research 253 (2017) 58–63
I. Niedtfeld
studies to use more difficult stimulus material and/or time limitation. In future research, it is important to include a wider spectrum of emotional categories, first and foremost anger because it has a high relevance in BPD (Mancke et al., 2015). Likewise, one may argue that difficulties in BPD could be more pronounced with regard to the recognition of positive emotions (e.g. pride, joy, affection). Finally, we assessed congruent emotional reactions as a measure of emotional empathy, which is suitable to study emotional contagion. However, we did not investigate more complex forms of emotional empathy (Singer and Klimecki, 2014), which require complex mentalizing and lead to emotions like compassion. It is important to notice that these complex forms might also be disturbed in BPD (Flasbeck et al., 2017; Petersen et al., 2016) and should be investigated in further research.
Descriptively, BPD patients showed higher rates of correct emotion recognition compared to HC when facial expressions were set to neutral, although the group by condition interaction was not significant. Nevertheless, this might be an interesting starting point for further research. After the emotion recognition task, subjects indicated their level of confidence with regard to their decision. Results are in line with two other studies reporting decreased confidence ratings in BPD (Kaletsch et al., 2014; Thome et al., 2016). In everyday life, social interaction is nearly always marked by uncertainty with regard to the emotions or intentions of others. Since uncertainty with regard to emotion recognition leads to aversive states and might also delay social engagement (Beaupre and Hess, 2006), high uncertainty in BPD may impede prosocial behavior and result in social withdrawal. As a measure of emotional empathy, subjects rated their own emotional reaction to every video. When information from all communication channels carried the same emotion, those with BPD showed decreased emotional empathy compared to HC, which is in line with a previous study that used a behavioral measure of emotional empathy (Dziobek et al., 2011). According to exploratory analyses, this difference was present in every emotional valence condition, and we observed medium effect sizes for happy, disgusted (with another person), and neutral emotional valence. However, only the neutral valence was significant after correcting for multiple comparisons. It seems that the current emotional state of the patients overruled their empathic reaction, which is in line with the notion that own negative emotional states might interfere with affective empathy in BPD (Roepke et al., 2012). Correspondingly, it was noted that BPD patients are less familiar with happy or neutral feelings, rarely experiencing them in daily life (Ebner-Priemer et al., 2007). Conversely to low emotional empathy in response to full emotional expressions, those with BPD showed higher emotional empathy than HC when the speech content was neutral, but facial expression and prosody carried an emotion. It has to be noted that HC showed low emotional empathy in this condition, which is in line with a study using the same experimental paradigm in a sample of healthy participants (Regenbogen et al., 2012a), reporting the lowest rates of emotional empathy in the condition with neutral speech content. Contrariwise, patients with BPD showed an increased rate of emotional empathy / emotional contagion, although the speech content was neutral. Exploratory analyses reveal that this was most pronounced for stimuli involving sadness and fear. These results complement findings of enhanced sensitivity to nonverbal cues in BPD (Frank and Hoffman, 1986), suggesting BPD patients to be more susceptible to emotional information expressed via nonverbal cues than HC. Additionally, sadness and fear are emotions often experienced by BPD patients in daily life (Ebner-Priemer et al., 2007). This should encourage therapists to use this knowledge to foster the therapeutic relationship with BPD patients by discussing potential misunderstandings with regard to nonverbal communication (Bedics et al., 2012).
4.2. Conclusions This study is the fourth investigating behavioral measures of emotional empathy in BPD, and it offers new insights regarding the effect of inconsistencies between verbal and nonverbal information. BPD patients emotionally resonated to a greater extent in response to nonverbally expressed emotions as compared to HC, which was most pronounced for sadness and fear. Simultaneously, they showed decreased emotional empathy when they were confronted with full emotional expressions, especially for neutral emotional valence. With regard to cognitive empathy, those with BPD showed no differences in emotion recognition accuracy as compared to healthy controls, possibly related to low task difficulty. However, those with BPD reported greater uncertainty with regard to their decision. It can be concluded that ambiguity, which is frequently present in social interaction, has an effect on empathic reactions in BPD, possibly hindering adequate social responses. Conflict of interest None. Acknowledgement The research reported on was supported by a grant to the author from the German Research Foundation (grant number NI 1591/1-1). I thank Lisa Störkel, Nadine Defiebre, Linda Spettel, and Meltem Karakaya for their help with the data acquisition and Lars Schulze and Christian Schmahl for their helpful comments on the first paper draft. Appendix A. Supporting information Supplementary data associated with this article can be found in the online version at http://dx.doi//10.1016/j.psychres.2017.03.037. References
4.1. Limitations American Psychiatric Association, 2013. Diagnostic and statistical manual of mental disorders: DSM‐5 5. American Psychiatric Association, Arlington, VA. Argyle, M., Alkema, F., Gilmour, R., 1971. The communication of friendly and hostile attitudes by verbal and non-verbal signals. Eur. J. Soc. Psychol. 1 (3), 385–402. Baez, S., Marengo, J., Perez, A., Huepe, D., Font, F.G., Rial, V., et al., 2015. Theory of mind and its relationship with executive functions and emotion recognition in borderline personality disorder. J. Neuropsychol. 9 (2), 203–218. Beaupre, M.G., Hess, U., 2006. An ingroup advantage for confidence in emotion recognition judgments: the moderating effect of familiarity with the expressions of outgroup members. Pers. Soc. Psychol. Bull. 32 (1), 16–26. Bedics, J.D., Atkins, D.C., Comtois, K.A., Linehan, M.M., 2012. Weekly therapist ratings of the therapeutic relationship and patient introject during the course of dialectical behavioral therapy for the treatment of borderline personality disorder. Psychotherapy 49 (2), 231–240. Bohus, M., Kleindienst, N., Limberger, M.F., Stieglitz, R.D., Domsalla, M., Chapman, A.L., et al., 2009. The short version of the borderline symptom List (BSL-23): development and initial data on psychometric properties. Psychopathology 42 (1), 32–39.
While the present study had a number of strengths, including the parallel investigation of cognitive and emotional empathy at the behavioral level in BPD, using ecologically valid stimulus material, it is also limited in some ways. First, this study did not include a clinical control group and it did only investigate female subjects. Therefore, findings cannot be attributed specifically to BPD pathology, nor generalized to male BPD patients. Next, the gender of the interaction partner might be an important variable when studying empathy in BPD. In this investigation, the number of male/female actors in each experimental condition was not equal. Therefore, further research should directly investigate gender effects on emotional empathy. Furthermore, the non-significant findings with regard to emotion recognition may well be caused by a ceiling effect, encouraging further 62
Psychiatry Research 253 (2017) 58–63
I. Niedtfeld
functioning in borderline personality disorder: a systematic review of behavioral and laboratory-based assessments. Clin. Psychol. Rev. 34 (3), 193–205. Lowyck, B., Luyten, P., Vanwalleghem, D., Vermote, R., Mayes, L.C., Crowley, M.J., 2016. What's in a face? Mentalizing in borderline personality disorder based on dynamically changing facial expressions. Personal. Disord. 7 (1), 72–79. Lynch, T.R., Rosenthal, M.Z., Kosson, D.S., Cheavens, J.S., Lejuez, C.W., Blair, R.J., 2006. Heightened sensitivity to facial expressions of emotion in borderline personality disorder. Emotion 6 (4), 647–655. Mancke, F., Herpertz, S.C., Bertsch, K., 2015. Aggression in borderline personality disorder: a multidimensional model. Personal. Disord. 6 (3), 278–291. Matzke, B., Herpertz, S.C., Berger, C., Fleischer, M., Domes, G., 2014. Facial reactions during emotion recognition in borderline personality disorder: a facial electromyography study. Psychopathology 47 (2), 101–110. Mier, D., Lis, S., Esslinger, C., Sauer, C., Hagenhoff, M., Ulferts, J., et al., 2013. Neuronal correlates of social cognition in borderline personality disorder. Soc. Cogn. Affect. Neurosci. 8 (5), 531–537. Minzenberg, M.J., Poole, J.H., Vinogradov, S., 2006. Social-emotion recognition in borderline personality disorder. Compr. Psychiatry 47 (6), 468–474. Mitchell, A.E., Dickens, G.L., Picchioni, M.M., 2014. Facial emotion processing in borderline personality disorder: a systematic review and meta-analysis. Neuropsychol. Rev. 24 (2), 166–184. New, A.S., aan het Rot, M., Ripoll, L.H., Perez-Rodriguez, M.M., Lazarus, S., Zipursky, E., et al., 2012. Empathy and alexithymia in borderline personality disorder: clinical and laboratory measures. J. Pers. Disord. 26 (5), 660–675. Niedtfeld, I., Defiebre, N., Regenbogen, C., Mier, D., Fenske, S., Kirsch, P., et al., 2016. Facing the problem: impaired emotion recognition during multimodal social information processing in borderline personality disorder. J. Pers. Disord., 1–16. Petersen, R., Brakoulias, V., Langdon, R., 2016. An experimental investigation of mentalization ability in borderline personality disorder. Compr. Psychiatry 64, 12–21. Preissler, S., Dziobek, I., Ritter, K., Heekeren, H.R., Roepke, S., 2010. Social cognition in borderline personality disorder: evidence for disturbed recognition of the emotions, thoughts, and intentions of others. Front. Behav. Neurosci. 4, 182. Regenbogen, C., Habel, U., Kellermann, T., 2013. Connecting multimodality in human communication. Front. Hum. Neurosci. 7, 754. Regenbogen, C., Schneider, D.A., Finkelmeyer, A., Kohn, N., Derntl, B., Kellermann, T., et al., 2012a. The differential contribution of facial expressions, prosody, and speech content to empathy. Cogn. Emot. 26 (6), 995–1014. Regenbogen, C., Schneider, D.A., Gur, R.E., Schneider, F., Habel, U., Kellermann, T., 2012b. Multimodal human communication–Targeting facial expressions, speech content and prosody. Neuroimage 60 (4), 2346–2356. Robin, M., Pham-Scottez, A., Curt, F., Dugre-Le Bigre, C., Speranza, M., Sapinho, D., et al., 2012. Decreased sensitivity to facial emotions in adolescents with borderline personality disorder. Psychiatry Res. 200 (2–3), 417–421. Roepke, S., Vater, A., Preissler, S., Heekeren, H.R., Dziobek, I., 2012. Social cognition in borderline personality disorder. Front. Neurosci. 6, 195. Schilling, L., Wingenfeld, K., Lowe, B., Moritz, S., Terfehr, K., Kother, U., et al., 2012. Normal mind-reading capacity but higher response confidence in borderline personality disorder patients. Psychiatry Clin. Neurosci. 66 (4), 322–327. Schneider, D., Regenbogen, C., Kellermann, T., Finkelmeyer, A., Kohn, N., Derntl, B., et al., 2012. Empathic behavioral and physiological responses to dynamic stimuli in depression. Psychiatry Res. 200 (2–3), 294–305. Schneider, K., Regenbogen, C., Pauly, K.D., Gossen, A., Schneider, D.A., Mevissen, L., et al., 2013. Evidence for gender-specific endophenotypes in high-functioning autism spectrum disorder during empathy. Autism Res. 6 (6), 506–521. Sharp, C., Pane, H., Ha, C., Venta, A., Patel, A.B., Sturek, J., et al., 2011. Theory of mind and emotion regulation difficulties in adolescents with borderline traits. J. Am. Acad. Child Adolesc. Psychiatry 50 (6), (563-573 e561). Singer, T., Klimecki, O.M., 2014. Empathy and compassion. Curr. Biol. 24 (18), R875–R878. Stiglmayr, C., Schimke, P., Wagner, T., Braakmann, D., Schweiger, U., Sipos, V., et al., 2010. Development and psychometric characteristics of the Dissociation Tension Scale. J. Pers. Assess. 92 (3), 269–277. Thome, J., Liebke, L., Bungert, M., Schmahl, C., Domes, G., Bohus, M., et al., 2016. Confidence in facial emotion recognition in borderline personality disorder. Personal. Disord. 7 (2), 159–168. v Ceumern-Lindenstjerna, I.A., Brunner, R., Parzer, P., Frey, M., Fiedler, P., Resch, F., 2007. [Perception of emotional facial expressions in female adolescents with borderline personality disorder]. Z. Kinder Jugend. Psychother. 35 (5), 333–340. Wagner, A.W., Linehan, M.M., 1999. Facial expression recognition ability among women with borderline personality disorder: Implications for emotion regulation. J. Pers. Disord. 13 (4), 329–344. Watson, D., Clark, L.A., Tellegen, A., 1988. Development and validation of brief measures of positive and negative affect: the PANAS scales. J. Pers. Soc. Psychol. 54 (6), 1063–1070. Welch, S.S., Linehan, M.M., 2002. High-risk situations associated with parasuicide and drug use in borderline personality disorder. J. Pers. Disord. 16 (6), 561–569. Wingenfeld, K., Kuehl, L.K., Janke, K., Hinkelmann, K., Dziobek, I., Fleischer, J., et al., 2014. Enhanced emotional empathy after mineralocorticoid receptor stimulation in women with borderline personality disorder and healthy women. Neuropsychopharmacology 39 (8), 1799–1804. Wittchen, H.U., Wunderlich, U., Gruschwitz, S., 1997. SKID. Strukturiertes Klinisches Interview für DSM-IV Achse I. Hogrefe, Göttingen.
Brodsky, B.S., Groves, S.A., Oquendo, M.A., Mann, J.J., Stanley, B., 2006. Interpersonal precipitants and suicide attempts in borderline personality disorder. Suicide Life Threat. Behav. 36 (3), 313–322. Bruck, C., Derstroff, S., Jacob, H., Wolf-Arehult, M., Wekenmann, S., Wildgruber, D., 2016. Perception of verbal and nonverbal emotional signals in women with borderline personality disorder: evidence of a negative bias and an increased reliance on nonverbal cues. J. Pers. Disord., 1–11. Cohen, J., 1988. Statistical Power Analysis for the Behavioral Sciences 2nd ed.. Lawrence Erlbaum Associates, Hillsdale, NJ. Daros, A.R., Zakzanis, K.K., Ruocco, A.C., 2013. Facial emotion recognition in borderline personality disorder. Psychol. Med. 43 (9), 1953–1963. Davis, M.H., 1983. Measuring individual differences in empathy: evidence for a multidimensional approach. J. Pers. Soc. Psychol. 44 (1), 113–126. Davis, M.H., Hull, J.G., Young, R.D., Warren, G.G., 1987. Emotional reactions to dramatic film stimuli: the influence of cognitive and emotional empathy. J. Pers. Soc. Psychol. 52 (1), 126–133. Dinsdale, N., Crespi, B.J., 2013. The borderline empathy paradox: evidence and conceptual models for empathic enhancements in borderline personality disorder. J. Pers. Disord. 27 (2), 172–195. Domes, G., Czieschnek, D., Weidler, F., Berger, C., Fast, K., Herpertz, S.C., 2008. Recognition of facial affect in borderline personality disorder. J. Pers. Disord. 22 (2), 135–147. Dyck, M., Habel, U., Slodczyk, J., Schlummer, J., Backes, V., Schneider, F., et al., 2009. Negative bias in fast emotion discrimination in borderline personality disorder. Psychol. Med. 39 (5), 855–864. Dziobek, I., Preissler, S., Grozdanovic, Z., Heuser, I., Heekeren, H.R., Roepke, S., 2011. Neuronal correlates of altered empathy and social cognition in borderline personality disorder. Neuroimage 57 (2), 539–548. Dziobek, I., Rogers, K., Fleck, S., Bahnemann, M., Heekeren, H.R., Wolf, O.T., et al., 2008. Dissociation of cognitive and emotional empathy in adults with Asperger syndrome using the Multifaceted Empathy Test (MET). J. Autism Dev. Disord. 38 (3), 464–473. Ebner-Priemer, U.W., Welch, S.S., Grossman, P., Reisch, T., Linehan, M.M., Bohus, M., 2007. Psychophysiological ambulatory assessment of affective dysregulation in borderline personality disorder. Psychiatry Res. 150 (3), 265–275. Eisenberg, N., Miller, P.A., 1987. The relation of empathy to prosocial and related behaviors. Psychol. Bull. 101 (1), 91–119. Ekman, P., Friesen, W.V., 1971. Constants across cultures in the face and emotion. J. Pers. Soc. Psychol. 17 (2), 124–129. Flasbeck, V., Enzi, B., Brune, M., 2017. Altered empathy for psychological and physical pain in borderline personality disorder. J. Pers. Disord., 1–20. Frank, H., Hoffman, N., 1986. Borderline empathy: an empirical investigation. Compr. Psychiatry 27 (4), 387–395. Fydrich, T., Renneberg, B., Schmitz, B., Wittchen, H.‐U., 1997. SKID-II-Strukturiertes Klinisches Interview für DSM-IV Achse II: Persönlichkeitsstörungen. [SCID-II. The structured clinical interview for DSM-IV, axis II. Personality disorders]. Hogrefe, Göttingen. Gunderson, J.G., 2007. Disturbed relationships as a phenotype for borderline personality disorder. Am. J. Psychiatry 164 (11), 1637–1640. Gunderson, J.G., Lyons-Ruth, K., 2008. BPD's interpersonal hypersensitivity phenotype: a gene-environment-developmental model. J. Pers. Disord. 22 (1), 22–41. Gunderson, J.G., Stout, R.L., McGlashan, T.H., Shea, M.T., Morey, L.C., Grilo, C.M., et al., 2011. Ten-year course of borderline personality disorder: psychopathology and function from the collaborative longitudinal personality disorders study. Arch. Gen. Psychiatry 68 (8), 827–837. Guttman, H.A., Laporte, L., 2000. Empathy in families of women with borderline personality disorder, anorexia nervosa, and a control group. Fam. Process. 39 (3), 345–358. Harari, H., Shamay-Tsoory, S.G., Ravid, M., Levkovitz, Y., 2010. Double dissociation between cognitive and affective empathy in borderline personality disorder. Psychiatry Res. 175 (3), 277–279. Hatfield, E., Cacioppo, J.T., Rapson, R.L., 1993. Emotional contagion. Curr. Dir. Psychol. Sci. 2 (3), 96–100. Hatfield, E., Cacioppo, J.T., Rapson, R.L., 1994. Emotional Contagion. Cambridge University Press, New York, NY. Hepp, J., Lane, S.P., Carpenter, R.W., Niedtfeld, I., Brown, W.C., Trull, T.J., 2017. Interpersonal problems and negative affect in borderline personality and depressive disorders in daily life. Clin. Psychol. Sci., (2167702616677312). Herpertz, S.C., Bertsch, K., 2014. The social-cognitive basis of personality disorders. Curr. Opin. Psychiatry 27 (1), 73–77. Jacob, H., Kreifelts, B., Bruck, C., Erb, M., Hosl, F., Wildgruber, D., 2012. Cerebral integration of verbal and nonverbal emotional cues: impact of individual nonverbal dominance. Neuroimage 61 (3), 738–747. Jolliffe, D., Farrington, D.P., 2006. Development and validation of the basic empathy scale. J. Adolesc. 29 (4), 589–611. Kaletsch, M., Kruger, B., Pilgramm, S., Stark, R., Lis, S., Gallhofer, B., et al., 2014. Borderline personality disorder is associated with lower confidence in perception of emotional body movements. Front. Psychol. 5, 1262. Kalpakci, A., Vanwoerden, S., Elhai, J.D., Sharp, C., 2016. The independent Contributions of emotion Dysregulation and Hypermentalization to the "Double dissociation" of affective and cognitive empathy in female Adolescent inpatients With BPD. J. Pers. Disord. 30 (2), 242–260. Lazarus, S.A., Cheavens, J.S., Festa, F., Zachary Rosenthal, M., 2014. Interpersonal
63
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Experimental investigation of cognitive and affective empathy in borderline personality disorder: Effects of ambiguity in multimodal social information processing
MARK
⁎
Inga Niedtfeld
Department of Psychosomatic Medicine, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim / Heidelberg University, Germany
A R T I C L E I N F O
A BS T RAC T
Keywords: Borderline Personality Disorder Empathy Emotional intelligence Facial expressions Nonverbal Communication
Borderline personality disorder (BPD) is characterized by affective instability and interpersonal problems. In the context of social interaction, impairments in empathy are proposed to result in inadequate social behavior. In contrast to findings of reduced cognitive empathy, some authors suggested enhanced emotional empathy in BPD. It was investigated whether ambiguity leads to decreased cognitive or emotional empathy in BPD. Thirtyfour patients with BPD and thirty-two healthy controls were presented with video clips, which were presented through prosody, facial expression, and speech content. Experimental conditions were designed to induce ambiguity by presenting neutral valence in one of these communication channels. Subjects were asked to indicate the actors’ emotional valence, their decision confidence, and their own emotional state. BPD patients showed increased emotional empathy when neutral stories comprised nonverbally expressed emotions. In contrast, when all channels were emotional, patients showed lower emotional empathy than healthy controls. Regarding cognitive empathy, there were no significant differences between BPD patients and healthy control subjects in recognition accuracy, but reduced decision confidence in BPD. These results suggest that patients with BPD show altered emotional empathy, experiencing higher rates of emotional contagion when emotions are expressed nonverbally. The latter may contribute to misunderstandings and inadequate social behavior.
1. Introduction Borderline Personality Disorder (BPD) is characterized by a pervasive pattern of instability in emotion regulation, self-image, impulse control, and interpersonal relationships (APA, 2013). One of the most stable and debilitating symptoms in BPD are difficulties in interpersonal relationships (Gunderson, 2007; Gunderson et al., 2011). In the course of interpersonal conflict, patients are also more likely to show emotional hyperactivity and emotion dysregulation (Gunderson and Lyons-Ruth, 2008; Hepp et al., 2017), and show dysfunctional behaviors such as suicide attempts or non-suicidal self-injurious behavior (Brodsky et al., 2006; Welch and Linehan, 2002). In search of factors possibly causing interpersonal problems in BPD, previous research has pointed, among other factors, to difficulties in emotion recognition and empathy (for an overview, see (Lazarus et al., 2014)). Empathy, the ability to understand and experience the thoughts and emotions of interaction partners (Davis, 1983; Eisenberg and Miller, 1987), is crucial for successful social interaction. Two facets,
cognitive and affective empathy, are commonly distinguished (Davis et al., 1987). Cognitive empathy describes the ability to cognitively understand the perspective, reactions, and emotions of others. Overlapping constructs are mentalization and theory of mind. Closely related to cognitive empathy, emotion recognition is the ability to accurately determine the emotional states of others from their emotional expression (Ekman and Friesen, 1971). Affective empathy is conceptualized as emotional responding, which is congruent with the emotion of an interaction partner (Davis et al., 1987). Moreover, as a precursor of affective empathy, emotional contagion was described as an automated mirroring of the emotional reaction of another person (Hatfield et al., 1994), also present in babies and animals (Singer and Klimecki, 2014). Affective empathy is a less studied field in BPD than cognitive empathy (Dinsdale and Crespi, 2013; Roepke et al., 2012). 1.1. Self-reported empathy in BPD Five studies investigated affective and cognitive empathy using a
⁎ Correspondence address. Central Institute of Mental Health, University of Heidelberg, Department of Psychosomatic Medicine and Psychotherapy, PO Box 12 21 20, 68072 Mannheim, Germany. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.psychres.2017.03.037 Received 12 October 2016; Received in revised form 13 March 2017; Accepted 20 March 2017 Available online 23 March 2017 0165-1781/ © 2017 Elsevier B.V. All rights reserved.
Psychiatry Research 253 (2017) 58–63
I. Niedtfeld
empathy test (Dziobek et al., 2008), showing pictures of complex social situations to investigate cognitive and emotional empathy (“How much do you feel for the person?”). The first study reports deficits in this measure of affective empathy in BPD (Dziobek et al., 2011), the second does not find significant differences between BPD patients ad healthy controls (Wingenfeld et al., 2014). The third study assessed facial electromyography during a facial recognition task. The authors hypothesized that BPD patients show increased facial mimicry, which could be interpreted as a basal form of empathy (Matzke et al., 2014). However, the results of the study point to a general tendency in BPD to react with augmented activation of the corrugator supercilii muscle (i.e. frowning) to all displays of negative expressions. The authors interpreted this finding as evidence for a negativity bias, but not for heightened affective empathy in BPD.
self-report measure, the Interpersonal Reactivity Index (IRI; (Davis, 1983)). The first study found self-reported affective empathy on both IRI subscales (empathic concern and personal distress) to be higher in BPD than in nonclinical controls, whereas self-reports of cognitive empathy (i.e., the subscale perspective taking) was lower in the BPD group (Guttman and Laporte, 2000). Three other studies using the IRI also reported lower cognitive empathy with regard to the IRI subscale perspective taking (Dziobek et al., 2011; Harari et al., 2010; New et al., 2012). However, regarding affective empathy, findings are less clear: Three of the four studies found higher values on the subscale personal distress, but no significant effects for self-reported empathic concern (Dziobek et al., 2011; Matzke et al., 2014; New et al., 2012). Higher values in personal distress in BPD might result from heightened emotional contagion (Hatfield et al., 1993; Herpertz and Bertsch, 2014), while empathic concern was described as a more mature form of empathy (Singer and Klimecki, 2014), leading to emotions like compassion. However, one study did not find any significant differences between BPD patients and healthy controls with regard to affective empathy (Harari et al., 2010). Finally, a recent study found affective empathy to be higher in female adolescents with BPD than in psychiatric control patients (Kalpakci et al., 2016). Notably, the authors used the Basic Empathy Scale for self-reported emotional empathy (Jolliffe and Farrington, 2006), explicitly assessing congruent affective reactions.
1.4. The current study The current study was designed to investigate cognitive and affective empathy in BPD using multimodal stimuli with high ecological validity. Additionally, it is aimed at a deeper understanding of the influence of ambiguity on cognitive and emotional empathy in BPD. In contrast to our previous study (Niedtfeld et al., 2016), which investigated the recognition of isolated information channels (text only, video without audio, and audio only) as compared to videos (all channels containing the same emotion), in this study we focused on the impact of ambiguity between information channels. In daily life, communication is not always as clear as in the laboratory. There is evidence that inconsistencies between verbal and nonverbal information result in a larger influence of nonverbal cues on emotion ratings (Argyle et al., 1971; Jacob et al., 2012). A study in healthy controls found that inconsistencies between verbal and nonverbal information decrease emotion recognition and affective empathy differentially, dependent on the affected communication channel (Regenbogen et al., 2012a). A recent study on emotion recognition in BPD demonstrated that patients relied more on nonverbal cues when verbal and nonverbal signals were contradictory (Bruck et al., 2016). Since previous research suggests impairments in cognitive empathy in BPD, it was hypothesized that (1) BPD patients would show lower performance in emotion recognition than HC, and (2) this emotion recognition deficit would be most pronounced when stimuli are ambiguous. Furthermore, BPD patients were expected (3) to experience lower confidence with regard to the emotion recognition task. Finally, it was hypothesized that (4) those with BPD show altered affective empathy (i.e. experience of the same emotion as their interaction partner) as compared to healthy controls.
1.2. Behavioral measures of cognitive empathy in BPD A relatively large body of studies investigated emotion recognition abilities in BPD patients. Most of the studies asked patients with BPD and healthy controls (HC) to categorize an emotional expression from a picture or photograph. Two meta-analyses in BPD found reduced emotion categorization abilities (Daros et al., 2013; Mitchell et al., 2014). The authors conclude that patients more often rated neutral faces as negative emotional, and had difficulties with the detection of anger and disgust. However, one could argue that studies using images of facial expressions are lacking ecological validity, because social cognition is likely to rely on multimodal and dynamic stimuli. During everyday communication, cues from different communication channels have to be integrated, such as facial expressions, speech content, and prosody (Regenbogen et al., 2012a). Only a few studies used film clips to study emotion categorization in BPD (Baez et al., 2015; Preissler et al., 2010) and in adolescents with high versus low borderline traits (Sharp et al., 2011), confirming impairments in the recognition of emotions. A study by Minzenberg et al. (2006) found impaired ability for emotion recognition only with integrated audiovisual stimuli, but not with isolated visual or auditory stimuli. A recent study from our own group tested whether difficulties in emotion recognition in BPD are based on deficits in the recognition of isolated social cues (Niedtfeld et al., 2016), and showed reduced emotion recognition abilities in BPD whenever facial expressions were presented. In addition to emotion recognition abilities, confidence in emotion judgements was investigated in four studies, asking how confident subjects were with regard to their decisions. Two studies (Kaletsch et al., 2014; Thome et al., 2016) reported lower confidence in ratings of emotion intensity in BPD, the first with regard to the emotional valence of body movements, the second with regard to facial expressions. One study showed enhanced confidence in BPD (Schilling et al., 2012), using the reading the mind in the eyes test. A recent study using dynamic stimuli of facial expressions found no difference with regard to confidence ratings between BPD and HC (Lowyck et al., 2016).
2. Methods 2.1. Participants Thirty-five unmedicated women diagnosed with BPD according to the DSM-IV (APA, 2013) and 32 healthy women were invited to participate in the study. Healthy subjects were recruited by newspaper advertisement, patients at the Department of Psychosomatic Medicine, Central Institute of Mental Health (CIMH) in Mannheim, Germany. Trained clinicians assessed BPD diagnosis and axis I comorbidities with the German version of the Structural Clinical Interview for DSMIV Axis-I (Wittchen et al., 1997) and Axis-II (Fydrich et al., 1997). Healthy subjects did not fulfil criteria of any axis I or II disorder. Exclusion criteria for patients were current substance abuse, bipolar disorder, schizophrenia, and a current severe depressive episode. One patient had to be excluded due to the disclosure of substance dependency after participation. Further assessments included self-ratings of BPD symptoms with the Borderline Symptom List-23 (BSL-23) (Bohus et al., 2009), current mood with the Positive and Negative Affect Schedule (PANAS) (Watson
1.3. Behavioral measures of affective empathy in BPD There are three studies assessing facets of affective empathy at the behavioral level in BPD (Dziobek et al., 2011; Matzke et al., 2014; Wingenfeld et al., 2014). Two of these studies used the multifaceted 59
Psychiatry Research 253 (2017) 58–63
I. Niedtfeld
sure). Finally, they had to indicate their own current emotion (disgusted, fearful, happy, sad, or neutral) as a measure for emotional empathy. They responded with three response buttons (skip left, skip right, enter). During the inter-trial-interval (~ 4.53 s), a white fixation cross on black background was shown. Skin conductance was recorded as a measure of sympathetic arousal during the experiment, but data will not be reported here.
Table 1 Main clinical data and self-report data of the sample. BPD (n=34)
Demographics Age (years) Education (years) Questionnaires BSL−23 DSS-Acute PANAS positive PANAS negative
HC (n=32)
Mean
SD
Mean
SD
p
28.26 11.41
8.11 1.64
31.16 11.48
8.47 1.61
0.16 0.86
1.93 2.02 2.32 1.87
0.72 0.93 0.50 0.53
0.16 1.06 2.93 1.07
0.19 0.15 0.71 0.09
< 0.001 < 0.001 < 0.001 < 0.001
2.3. Statistical analyses
et al., 1988), and dissociative symptoms with the Dissociation Tension Scale acute (DSS-acute) (Stiglmayr et al., 2010). The DSS-acute is a self-rating instrument, consisting of 21 items assessing psychological (e.g., derealization, depersonalization, amnesia) and somatic dissociation (e.g., perception of pain, vision and hearing). Participants gave written informed consent after they received a full description of the study protocol. The study was approved by the ethics committee of the Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg. The final sample consisted of 34 patients with BPD and 32 healthy controls, which did not differ in years of education (t(63) = 0.179; p=0.86) or age (t(64) = 1.416; p=0.16), see Table 1 for more details on demographics and self-report measures. Borderline patients had on average 1.94 current comorbid Axis I diagnoses, which included current depressive disorders (n=20); anxiety disorders (n=12); posttraumatic stress disorder (15); somatoform disorders (n=1); eating disorders (n=6); substance use, but abstinent for at least 2 months (n=5); substance dependency lifetime, but abstinent for at least one year (n=5); and attention deficit hyperactivity disorder (n =2).
To test the four hypotheses, a repeated measure analyses of variance (rmANOVA) was calculated, entering group (BPD vs. HC) as between-subjects factor, experimental condition (all emotional, neutral face, neutral prosody, and neutral speech content) as within-subjects factor, and the respective dependent variable (percentage accuracy scores, mean confidence ratings, percentage of empathic reactions). Emotional valence (disgusted, fearful, happy, sad, or neutral) was not introduced as an additional within-subjects factor for two reasons. First, this would have led to an unbalanced factorial design, since neutral valence is only feasible within the condition all emotional. Additionally, the number of observations within the cells of a 2×4×5factorial design would be n=4, leading to violation of the assumptions of variance homogeneity and normality of the distribution. Means and standard deviations for each valence within each experimental condition are presented in Supplemental Tables 1 and 2. Level of significance was set to p < 0.05. If Mauchly's test of sphericity was significant (p < 0.05), Greenhouse–Geisser correction was applied. For post-hoc group comparisons within experimental conditions, corrected degrees of freedom are reported in case of unequal variances (as indicated by Levene's test). To correct for multiple comparisons, the Holm-Bonferroni procedure was applied. For each experimental condition, effect size Cohens d was computed between BPD and HC. According to Cohen (1988), an effect size of d =0.2 reflects a small effect, d = 0.5 a medium and d =0.8 a large effect size.
2.2. Stimulus material & procedure
3. Results
The stimulus material was developed by Regenbogen et al. (2012a), and was previously applied in healthy participants (Regenbogen et al., 2013, 2012b), patients with autism spectrum disorder (Schneider et al., 2013), and patients with depression (Schneider et al., 2012). Each trial consisted of a short video clip (~12 s) showing a person telling a selfrelated story with different emotional valence (disgust, fear, joy, sadness, neutral). The experimental conditions were designed to induce ambiguity by setting the emotionality of one communication channel (speech content, facial expression, prosody) to neutral. In the condition all emotional, a person tells a self-relevant emotional story with corresponding prosody and emotional facial expression. In the conditions neutral face, neutral prosody, and neutral speech content, the respective channel incorporates a neutral valence, while the two remaining channels comprise the target emotion. For example, in the condition neutral speech content, a person says: “Last night I cleaned up the pantry. Then I went to brush my teeth in the bathroom. I watched TV for a short time and went to bed”. At the same time, her facial expression and prosody point to fear. After participants gave informed consent, filled out the questionnaires and received the task instruction, they completed three practice trials. Within every trial of the experiment, subjects were presented with a random sequence of 80 video stimuli (16 trials per experimental condition and per valence), showing 12 different persons. Every video was unique with regard to the content and was shown only once. After every video, subjects were asked to label the presented emotion with one out of five choices (disgusted, fearful, happy, sad, and neutral) without any time limit. Afterwards, they indicated how confident they were in their decision on a 6–point-likert-scale (1= very unsure, 6=very
3.1. Cognitive empathy
BPD: Borderline Personality Disorder; HC: Healthy Control Subjects; BSL-23: Borderline Symptom List (general score); PANAS: Positive and negative affect schedule, subscales positive and negative affect; DSS-Acute: Dissociation Tension Scale.
As dependent variable, percentage accuracy scores for the emotion recognition task were calculated for every experimental condition (all emotional, neutral face, neutral prosody, and neutral speech content) across all emotions. A repeated measure analysis of variance (rmANOVA) was calculated with group (BPD vs. HC) as betweensubjects factor, experimental condition as within-subjects factor, and the percentage accuracy score as dependent variable. Results showed a significant main effect for condition (F(1.68,107.33) = 41.552, p < 0.001, ηp2 = 0.40). Post-hoc pairwise comparisons exploring the main effect of condition pointed to significant different percentage accuracy scores between every condition (all emotional > neutral prosody > neutral face > neutral speech content, all p < 0.001). We did not observe a significant main effect for group (F(1, 64) = 0.118, p=0.37 (one-sided), ηp2 =0.002) or interaction effect (F(1.68,107.33) =1.861,p = 0.138, ηp2 =0.03). In conclusion, the first and second hypotheses regarding impaired emotion recognition in BPD were not confirmed. Table 2 provides means, standard deviations, and the effect size Cohens d for correct emotion recognition. The confidence of the subjects in their emotion recognition decision was analyzed with rmANOVA, again entering group (BPD vs. HC) and experimental condition as independent variables, and the mean confidence rating as dependent variable. Results showed a significant main effect for condition (F(2.139,136.923) = 56.987, p < 0.001, ηp2 = 0.47), and a significant main effect for group (F(1, 64) = 2.968, p < 0.05 (onesided), ηp2 = 0.04), but no significant interaction effect for group×condition (F(2.139,136.923) = 0.063, p = 0.95, ηp2 = 0.001). In every 60
Psychiatry Research 253 (2017) 58–63
I. Niedtfeld
Table 2 Means, standard deviations and effect sizes for the accuracy scores in percent. The respective rmANOVA resulted in a significant main effect of condition, but no significant effects for group or group by condition interaction. Condition
All emotional neutral content Neutral face Neutral prosody
BPD (n =34)
HC (n =32)
Mean
SD
Mean
SD
HC > BPD
95.50 81.80 73.16 88.97
5.72 16.88 18.81 9.86
96.29 83.79 65.23 91.41
3.68 13.27 27.63 8.21
0.17 0.13 −0.34 0.27
Table 4 Means, standard deviations and effect sizes for empathic reactions in percent. The respective rmANOVA resulted in significant results for the main effect condition and the group by condition interaction.
effect size d
Condition
all emotional neutral content neutral face neutral prosody *
All emotional Neutral content Neutral face Neutral prosody
BPD (n=34)
HC (n=32)
Effect size d
Mean
SD
Mean
SD
HC > BPD
4.23 4.61
0.97 1.04 1.03 0.94
5.24 4.26 4.53 4.98
0.61 0.82 0.86 0.73
0.41 0.36 0.32 0.44
HC (n=32)
effect size d
Mean
SD
Mean
SD
HC > BPD
75.09 36.76 45.22 55.70
14.13 29.98 26.34 28.34
85.84 20.31 55.47 66.41
13.07 22.78 27.94 25.09
0.79* −0.62* 0.38 0.40
=p < 0.05, Post-Hoc T-tests, Holm-Bonferroni corrected.
Subsequently, follow-up exploratory analyses were calculated in order to test whether the emotional valence had an effect within the significant experimental conditions. To correct for multiple comparisons, the Holm-Bonferroni procedure was applied. For the condition all emotional, where BPD patients showed reduced emotional empathy, Post hoc t - tests of emotional empathy for each emotional valence (neutral, happy, sad, fear, disgust) were calculated. BPD patients descriptively showed reduced emotional empathy in response to every emotional valence, and differed significantly from HC when the condition all emotional included neutral (t(50.276)=3.363, p < 0.05 (Holm-Bonferroni corrected), d=0.85) emotional valence. For the experimental condition with neutral content, post hoc t - tests of emotional empathy were calculated for each presented emotional valence (happy, sad, fear, disgust). Again, BPD patients descriptively showed increased emotional empathy with regard to every emotional valence, and differences to HC were significant when sadness (t(59.676) = 2.701, p < 0.05 (Holm-Bonferroni corrected), d = 0.67) or fear (t(57.231) = 2.560, p < 0.05 (Holm-Bonferroni corrected), d = 0.64) were displayed in facial expression and prosody, although the speech content was neutral.
Table 3 Means, standard deviations and effect sizes for confidence (1= very unsure, 6=very sure) during emotion recognition task. The respective rmANOVA resulted in a significant main effect of condition and group, but no significant group by condition interaction. Condition
BPD (n=34)
experimental condition, patients were less confident regarding their emotion recognition than HC, confirming the third hypothesis (see Table 3).
3.2. Affective empathy With regard to the third hypothesis related to empathic reactions, another rmANOVA was conducted with group and experimental condition as independent variables, and the percentage of empathic reactions (i.e. own reported emotion = target emotion) as dependent variable. Results showed a significant main effect for condition (F(2.075,132.802) =119.346, p < 0.001, ηp2 = 0.65), but no significant main effect for group (F(1, 64) = 0.607, p = 0.439, ηp2 = 0.009). A significant group by condition interaction effect (F(2.075,132.802) =11.62, p < 0.001, ηp2 = 0.15) was observed. Post hoc t - tests revealed reduced affective empathy in BPD in the condition all emotional (t(64) = 3.202, p < 0.01 (Holm-Bonferroni corrected), d=0.79), and enhanced affective empathy in the condition neutral content (t(61.337) = 2.519, p < 0.05 (Holm-Bonferroni corrected), d=0.62). Therefore, the third hypothesis regarding altered affective empathy in BPD was confirmed. The results on affective empathy are depicted in Fig. 1. Table 4 provides means, standard deviations, and effect sizes for empathic reactions.
4. Discussion In this study, cognitive and affective empathy in BPD were investigated, using ecologically valid video stimulus material. During the task, subjects rated emotions in short video clips that provided emotional information via three different channels: Speech content, prosody and facial expression. In order to investigate the effect of decreased clarity or ambiguity, experimental manipulation involved conditions where each of these information channels was set to neutral. Cognitive empathy was tested with a classical forced-choice emotion recognition task. There was no evidence for impaired emotion recognition abilities in BPD compared to HC. This is in line with some previous studies reporting on emotion recognition of full emotional facial expressions in BPD vs HC (Domes et al., 2008; Dyck et al., 2009; Lynch et al., 2006; Mier et al., 2013; Robin et al., 2012; v CeumernLindenstjerna et al., 2007; Wagner and Linehan, 1999), but not in line with studies that used complex stimulus material like video clips to investigate cognitive empathy (Dziobek et al., 2011; Niedtfeld et al., 2016; Preissler et al., 2010). One explanation could be that there was no time limit for the decision process (Dyck et al., 2009). Comparing the condition all emotional between our first study (Niedtfeld et al., 2016) and the present study, the mean values of correct emotion recognition was comparable in BPD patients (94.29% versus 95.50%) and healthy control subjects (97.23% versus 96.29%). However, low differences with regard to the other experimental conditions in the present study resulted in a nonsignificant group by condition interaction effect. Based on the overall high rates of correct emotion recognition in the current study, one can assume that the current task had a low difficulty, which consequently may have caused a ceiling effect. Only in the experimental condition with neutral facial expression, accuracy scores were lower than 80% in both groups.
Fig. 1. Empathic reactions in Patients with BPD (grey bars) and HC (white bars), dependent on the experimental condition. *=p < 0.05, Post-Hoc T-tests, HolmBonferroni corrected.
61
Psychiatry Research 253 (2017) 58–63
I. Niedtfeld
studies to use more difficult stimulus material and/or time limitation. In future research, it is important to include a wider spectrum of emotional categories, first and foremost anger because it has a high relevance in BPD (Mancke et al., 2015). Likewise, one may argue that difficulties in BPD could be more pronounced with regard to the recognition of positive emotions (e.g. pride, joy, affection). Finally, we assessed congruent emotional reactions as a measure of emotional empathy, which is suitable to study emotional contagion. However, we did not investigate more complex forms of emotional empathy (Singer and Klimecki, 2014), which require complex mentalizing and lead to emotions like compassion. It is important to notice that these complex forms might also be disturbed in BPD (Flasbeck et al., 2017; Petersen et al., 2016) and should be investigated in further research.
Descriptively, BPD patients showed higher rates of correct emotion recognition compared to HC when facial expressions were set to neutral, although the group by condition interaction was not significant. Nevertheless, this might be an interesting starting point for further research. After the emotion recognition task, subjects indicated their level of confidence with regard to their decision. Results are in line with two other studies reporting decreased confidence ratings in BPD (Kaletsch et al., 2014; Thome et al., 2016). In everyday life, social interaction is nearly always marked by uncertainty with regard to the emotions or intentions of others. Since uncertainty with regard to emotion recognition leads to aversive states and might also delay social engagement (Beaupre and Hess, 2006), high uncertainty in BPD may impede prosocial behavior and result in social withdrawal. As a measure of emotional empathy, subjects rated their own emotional reaction to every video. When information from all communication channels carried the same emotion, those with BPD showed decreased emotional empathy compared to HC, which is in line with a previous study that used a behavioral measure of emotional empathy (Dziobek et al., 2011). According to exploratory analyses, this difference was present in every emotional valence condition, and we observed medium effect sizes for happy, disgusted (with another person), and neutral emotional valence. However, only the neutral valence was significant after correcting for multiple comparisons. It seems that the current emotional state of the patients overruled their empathic reaction, which is in line with the notion that own negative emotional states might interfere with affective empathy in BPD (Roepke et al., 2012). Correspondingly, it was noted that BPD patients are less familiar with happy or neutral feelings, rarely experiencing them in daily life (Ebner-Priemer et al., 2007). Conversely to low emotional empathy in response to full emotional expressions, those with BPD showed higher emotional empathy than HC when the speech content was neutral, but facial expression and prosody carried an emotion. It has to be noted that HC showed low emotional empathy in this condition, which is in line with a study using the same experimental paradigm in a sample of healthy participants (Regenbogen et al., 2012a), reporting the lowest rates of emotional empathy in the condition with neutral speech content. Contrariwise, patients with BPD showed an increased rate of emotional empathy / emotional contagion, although the speech content was neutral. Exploratory analyses reveal that this was most pronounced for stimuli involving sadness and fear. These results complement findings of enhanced sensitivity to nonverbal cues in BPD (Frank and Hoffman, 1986), suggesting BPD patients to be more susceptible to emotional information expressed via nonverbal cues than HC. Additionally, sadness and fear are emotions often experienced by BPD patients in daily life (Ebner-Priemer et al., 2007). This should encourage therapists to use this knowledge to foster the therapeutic relationship with BPD patients by discussing potential misunderstandings with regard to nonverbal communication (Bedics et al., 2012).
4.2. Conclusions This study is the fourth investigating behavioral measures of emotional empathy in BPD, and it offers new insights regarding the effect of inconsistencies between verbal and nonverbal information. BPD patients emotionally resonated to a greater extent in response to nonverbally expressed emotions as compared to HC, which was most pronounced for sadness and fear. Simultaneously, they showed decreased emotional empathy when they were confronted with full emotional expressions, especially for neutral emotional valence. With regard to cognitive empathy, those with BPD showed no differences in emotion recognition accuracy as compared to healthy controls, possibly related to low task difficulty. However, those with BPD reported greater uncertainty with regard to their decision. It can be concluded that ambiguity, which is frequently present in social interaction, has an effect on empathic reactions in BPD, possibly hindering adequate social responses. Conflict of interest None. Acknowledgement The research reported on was supported by a grant to the author from the German Research Foundation (grant number NI 1591/1-1). I thank Lisa Störkel, Nadine Defiebre, Linda Spettel, and Meltem Karakaya for their help with the data acquisition and Lars Schulze and Christian Schmahl for their helpful comments on the first paper draft. Appendix A. Supporting information Supplementary data associated with this article can be found in the online version at http://dx.doi//10.1016/j.psychres.2017.03.037. References
4.1. Limitations American Psychiatric Association, 2013. Diagnostic and statistical manual of mental disorders: DSM‐5 5. American Psychiatric Association, Arlington, VA. Argyle, M., Alkema, F., Gilmour, R., 1971. The communication of friendly and hostile attitudes by verbal and non-verbal signals. Eur. J. Soc. Psychol. 1 (3), 385–402. Baez, S., Marengo, J., Perez, A., Huepe, D., Font, F.G., Rial, V., et al., 2015. Theory of mind and its relationship with executive functions and emotion recognition in borderline personality disorder. J. Neuropsychol. 9 (2), 203–218. Beaupre, M.G., Hess, U., 2006. An ingroup advantage for confidence in emotion recognition judgments: the moderating effect of familiarity with the expressions of outgroup members. Pers. Soc. Psychol. Bull. 32 (1), 16–26. Bedics, J.D., Atkins, D.C., Comtois, K.A., Linehan, M.M., 2012. Weekly therapist ratings of the therapeutic relationship and patient introject during the course of dialectical behavioral therapy for the treatment of borderline personality disorder. Psychotherapy 49 (2), 231–240. Bohus, M., Kleindienst, N., Limberger, M.F., Stieglitz, R.D., Domsalla, M., Chapman, A.L., et al., 2009. The short version of the borderline symptom List (BSL-23): development and initial data on psychometric properties. Psychopathology 42 (1), 32–39.
While the present study had a number of strengths, including the parallel investigation of cognitive and emotional empathy at the behavioral level in BPD, using ecologically valid stimulus material, it is also limited in some ways. First, this study did not include a clinical control group and it did only investigate female subjects. Therefore, findings cannot be attributed specifically to BPD pathology, nor generalized to male BPD patients. Next, the gender of the interaction partner might be an important variable when studying empathy in BPD. In this investigation, the number of male/female actors in each experimental condition was not equal. Therefore, further research should directly investigate gender effects on emotional empathy. Furthermore, the non-significant findings with regard to emotion recognition may well be caused by a ceiling effect, encouraging further 62
Psychiatry Research 253 (2017) 58–63
I. Niedtfeld
functioning in borderline personality disorder: a systematic review of behavioral and laboratory-based assessments. Clin. Psychol. Rev. 34 (3), 193–205. Lowyck, B., Luyten, P., Vanwalleghem, D., Vermote, R., Mayes, L.C., Crowley, M.J., 2016. What's in a face? Mentalizing in borderline personality disorder based on dynamically changing facial expressions. Personal. Disord. 7 (1), 72–79. Lynch, T.R., Rosenthal, M.Z., Kosson, D.S., Cheavens, J.S., Lejuez, C.W., Blair, R.J., 2006. Heightened sensitivity to facial expressions of emotion in borderline personality disorder. Emotion 6 (4), 647–655. Mancke, F., Herpertz, S.C., Bertsch, K., 2015. Aggression in borderline personality disorder: a multidimensional model. Personal. Disord. 6 (3), 278–291. Matzke, B., Herpertz, S.C., Berger, C., Fleischer, M., Domes, G., 2014. Facial reactions during emotion recognition in borderline personality disorder: a facial electromyography study. Psychopathology 47 (2), 101–110. Mier, D., Lis, S., Esslinger, C., Sauer, C., Hagenhoff, M., Ulferts, J., et al., 2013. Neuronal correlates of social cognition in borderline personality disorder. Soc. Cogn. Affect. Neurosci. 8 (5), 531–537. Minzenberg, M.J., Poole, J.H., Vinogradov, S., 2006. Social-emotion recognition in borderline personality disorder. Compr. Psychiatry 47 (6), 468–474. Mitchell, A.E., Dickens, G.L., Picchioni, M.M., 2014. Facial emotion processing in borderline personality disorder: a systematic review and meta-analysis. Neuropsychol. Rev. 24 (2), 166–184. New, A.S., aan het Rot, M., Ripoll, L.H., Perez-Rodriguez, M.M., Lazarus, S., Zipursky, E., et al., 2012. Empathy and alexithymia in borderline personality disorder: clinical and laboratory measures. J. Pers. Disord. 26 (5), 660–675. Niedtfeld, I., Defiebre, N., Regenbogen, C., Mier, D., Fenske, S., Kirsch, P., et al., 2016. Facing the problem: impaired emotion recognition during multimodal social information processing in borderline personality disorder. J. Pers. Disord., 1–16. Petersen, R., Brakoulias, V., Langdon, R., 2016. An experimental investigation of mentalization ability in borderline personality disorder. Compr. Psychiatry 64, 12–21. Preissler, S., Dziobek, I., Ritter, K., Heekeren, H.R., Roepke, S., 2010. Social cognition in borderline personality disorder: evidence for disturbed recognition of the emotions, thoughts, and intentions of others. Front. Behav. Neurosci. 4, 182. Regenbogen, C., Habel, U., Kellermann, T., 2013. Connecting multimodality in human communication. Front. Hum. Neurosci. 7, 754. Regenbogen, C., Schneider, D.A., Finkelmeyer, A., Kohn, N., Derntl, B., Kellermann, T., et al., 2012a. The differential contribution of facial expressions, prosody, and speech content to empathy. Cogn. Emot. 26 (6), 995–1014. Regenbogen, C., Schneider, D.A., Gur, R.E., Schneider, F., Habel, U., Kellermann, T., 2012b. Multimodal human communication–Targeting facial expressions, speech content and prosody. Neuroimage 60 (4), 2346–2356. Robin, M., Pham-Scottez, A., Curt, F., Dugre-Le Bigre, C., Speranza, M., Sapinho, D., et al., 2012. Decreased sensitivity to facial emotions in adolescents with borderline personality disorder. Psychiatry Res. 200 (2–3), 417–421. Roepke, S., Vater, A., Preissler, S., Heekeren, H.R., Dziobek, I., 2012. Social cognition in borderline personality disorder. Front. Neurosci. 6, 195. Schilling, L., Wingenfeld, K., Lowe, B., Moritz, S., Terfehr, K., Kother, U., et al., 2012. Normal mind-reading capacity but higher response confidence in borderline personality disorder patients. Psychiatry Clin. Neurosci. 66 (4), 322–327. Schneider, D., Regenbogen, C., Kellermann, T., Finkelmeyer, A., Kohn, N., Derntl, B., et al., 2012. Empathic behavioral and physiological responses to dynamic stimuli in depression. Psychiatry Res. 200 (2–3), 294–305. Schneider, K., Regenbogen, C., Pauly, K.D., Gossen, A., Schneider, D.A., Mevissen, L., et al., 2013. Evidence for gender-specific endophenotypes in high-functioning autism spectrum disorder during empathy. Autism Res. 6 (6), 506–521. Sharp, C., Pane, H., Ha, C., Venta, A., Patel, A.B., Sturek, J., et al., 2011. Theory of mind and emotion regulation difficulties in adolescents with borderline traits. J. Am. Acad. Child Adolesc. Psychiatry 50 (6), (563-573 e561). Singer, T., Klimecki, O.M., 2014. Empathy and compassion. Curr. Biol. 24 (18), R875–R878. Stiglmayr, C., Schimke, P., Wagner, T., Braakmann, D., Schweiger, U., Sipos, V., et al., 2010. Development and psychometric characteristics of the Dissociation Tension Scale. J. Pers. Assess. 92 (3), 269–277. Thome, J., Liebke, L., Bungert, M., Schmahl, C., Domes, G., Bohus, M., et al., 2016. Confidence in facial emotion recognition in borderline personality disorder. Personal. Disord. 7 (2), 159–168. v Ceumern-Lindenstjerna, I.A., Brunner, R., Parzer, P., Frey, M., Fiedler, P., Resch, F., 2007. [Perception of emotional facial expressions in female adolescents with borderline personality disorder]. Z. Kinder Jugend. Psychother. 35 (5), 333–340. Wagner, A.W., Linehan, M.M., 1999. Facial expression recognition ability among women with borderline personality disorder: Implications for emotion regulation. J. Pers. Disord. 13 (4), 329–344. Watson, D., Clark, L.A., Tellegen, A., 1988. Development and validation of brief measures of positive and negative affect: the PANAS scales. J. Pers. Soc. Psychol. 54 (6), 1063–1070. Welch, S.S., Linehan, M.M., 2002. High-risk situations associated with parasuicide and drug use in borderline personality disorder. J. Pers. Disord. 16 (6), 561–569. Wingenfeld, K., Kuehl, L.K., Janke, K., Hinkelmann, K., Dziobek, I., Fleischer, J., et al., 2014. Enhanced emotional empathy after mineralocorticoid receptor stimulation in women with borderline personality disorder and healthy women. Neuropsychopharmacology 39 (8), 1799–1804. Wittchen, H.U., Wunderlich, U., Gruschwitz, S., 1997. SKID. Strukturiertes Klinisches Interview für DSM-IV Achse I. Hogrefe, Göttingen.
Brodsky, B.S., Groves, S.A., Oquendo, M.A., Mann, J.J., Stanley, B., 2006. Interpersonal precipitants and suicide attempts in borderline personality disorder. Suicide Life Threat. Behav. 36 (3), 313–322. Bruck, C., Derstroff, S., Jacob, H., Wolf-Arehult, M., Wekenmann, S., Wildgruber, D., 2016. Perception of verbal and nonverbal emotional signals in women with borderline personality disorder: evidence of a negative bias and an increased reliance on nonverbal cues. J. Pers. Disord., 1–11. Cohen, J., 1988. Statistical Power Analysis for the Behavioral Sciences 2nd ed.. Lawrence Erlbaum Associates, Hillsdale, NJ. Daros, A.R., Zakzanis, K.K., Ruocco, A.C., 2013. Facial emotion recognition in borderline personality disorder. Psychol. Med. 43 (9), 1953–1963. Davis, M.H., 1983. Measuring individual differences in empathy: evidence for a multidimensional approach. J. Pers. Soc. Psychol. 44 (1), 113–126. Davis, M.H., Hull, J.G., Young, R.D., Warren, G.G., 1987. Emotional reactions to dramatic film stimuli: the influence of cognitive and emotional empathy. J. Pers. Soc. Psychol. 52 (1), 126–133. Dinsdale, N., Crespi, B.J., 2013. The borderline empathy paradox: evidence and conceptual models for empathic enhancements in borderline personality disorder. J. Pers. Disord. 27 (2), 172–195. Domes, G., Czieschnek, D., Weidler, F., Berger, C., Fast, K., Herpertz, S.C., 2008. Recognition of facial affect in borderline personality disorder. J. Pers. Disord. 22 (2), 135–147. Dyck, M., Habel, U., Slodczyk, J., Schlummer, J., Backes, V., Schneider, F., et al., 2009. Negative bias in fast emotion discrimination in borderline personality disorder. Psychol. Med. 39 (5), 855–864. Dziobek, I., Preissler, S., Grozdanovic, Z., Heuser, I., Heekeren, H.R., Roepke, S., 2011. Neuronal correlates of altered empathy and social cognition in borderline personality disorder. Neuroimage 57 (2), 539–548. Dziobek, I., Rogers, K., Fleck, S., Bahnemann, M., Heekeren, H.R., Wolf, O.T., et al., 2008. Dissociation of cognitive and emotional empathy in adults with Asperger syndrome using the Multifaceted Empathy Test (MET). J. Autism Dev. Disord. 38 (3), 464–473. Ebner-Priemer, U.W., Welch, S.S., Grossman, P., Reisch, T., Linehan, M.M., Bohus, M., 2007. Psychophysiological ambulatory assessment of affective dysregulation in borderline personality disorder. Psychiatry Res. 150 (3), 265–275. Eisenberg, N., Miller, P.A., 1987. The relation of empathy to prosocial and related behaviors. Psychol. Bull. 101 (1), 91–119. Ekman, P., Friesen, W.V., 1971. Constants across cultures in the face and emotion. J. Pers. Soc. Psychol. 17 (2), 124–129. Flasbeck, V., Enzi, B., Brune, M., 2017. Altered empathy for psychological and physical pain in borderline personality disorder. J. Pers. Disord., 1–20. Frank, H., Hoffman, N., 1986. Borderline empathy: an empirical investigation. Compr. Psychiatry 27 (4), 387–395. Fydrich, T., Renneberg, B., Schmitz, B., Wittchen, H.‐U., 1997. SKID-II-Strukturiertes Klinisches Interview für DSM-IV Achse II: Persönlichkeitsstörungen. [SCID-II. The structured clinical interview for DSM-IV, axis II. Personality disorders]. Hogrefe, Göttingen. Gunderson, J.G., 2007. Disturbed relationships as a phenotype for borderline personality disorder. Am. J. Psychiatry 164 (11), 1637–1640. Gunderson, J.G., Lyons-Ruth, K., 2008. BPD's interpersonal hypersensitivity phenotype: a gene-environment-developmental model. J. Pers. Disord. 22 (1), 22–41. Gunderson, J.G., Stout, R.L., McGlashan, T.H., Shea, M.T., Morey, L.C., Grilo, C.M., et al., 2011. Ten-year course of borderline personality disorder: psychopathology and function from the collaborative longitudinal personality disorders study. Arch. Gen. Psychiatry 68 (8), 827–837. Guttman, H.A., Laporte, L., 2000. Empathy in families of women with borderline personality disorder, anorexia nervosa, and a control group. Fam. Process. 39 (3), 345–358. Harari, H., Shamay-Tsoory, S.G., Ravid, M., Levkovitz, Y., 2010. Double dissociation between cognitive and affective empathy in borderline personality disorder. Psychiatry Res. 175 (3), 277–279. Hatfield, E., Cacioppo, J.T., Rapson, R.L., 1993. Emotional contagion. Curr. Dir. Psychol. Sci. 2 (3), 96–100. Hatfield, E., Cacioppo, J.T., Rapson, R.L., 1994. Emotional Contagion. Cambridge University Press, New York, NY. Hepp, J., Lane, S.P., Carpenter, R.W., Niedtfeld, I., Brown, W.C., Trull, T.J., 2017. Interpersonal problems and negative affect in borderline personality and depressive disorders in daily life. Clin. Psychol. Sci., (2167702616677312). Herpertz, S.C., Bertsch, K., 2014. The social-cognitive basis of personality disorders. Curr. Opin. Psychiatry 27 (1), 73–77. Jacob, H., Kreifelts, B., Bruck, C., Erb, M., Hosl, F., Wildgruber, D., 2012. Cerebral integration of verbal and nonverbal emotional cues: impact of individual nonverbal dominance. Neuroimage 61 (3), 738–747. Jolliffe, D., Farrington, D.P., 2006. Development and validation of the basic empathy scale. J. Adolesc. 29 (4), 589–611. Kaletsch, M., Kruger, B., Pilgramm, S., Stark, R., Lis, S., Gallhofer, B., et al., 2014. Borderline personality disorder is associated with lower confidence in perception of emotional body movements. Front. Psychol. 5, 1262. Kalpakci, A., Vanwoerden, S., Elhai, J.D., Sharp, C., 2016. The independent Contributions of emotion Dysregulation and Hypermentalization to the "Double dissociation" of affective and cognitive empathy in female Adolescent inpatients With BPD. J. Pers. Disord. 30 (2), 242–260. Lazarus, S.A., Cheavens, J.S., Festa, F., Zachary Rosenthal, M., 2014. Interpersonal
63