Emotional Processing in Personality Disorder

Sabine C. Herpertz, MD
Emotional Instability and Borderline Personality Disorder
Affective instability is regarded as one of the basic factors of BPD [1], which, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, is conceptualized as a marked reactivity of mood. A theory provided by Linehan [2] proposes that affective hyperresponsiveness includes high sensitivity to emotional stimuli, high emotional intensity, and slow return of emotional arousal to baseline. This theory is supported by two currently published studies. Based on several self-report instruments, BPD patients showed higher affective lability and higher affective intensity compared with patients with other personality disorders [3]. Assuming that the experience of strong aversive tension may be an indicator of the extent of affect dysregulation, women with BPD reported significantly enhanced intensity and duration of subjectively perceived states of aversive tension compared with healthy control individuals [4]. Psychologic tasks Very few experimental studies have been performed that focused on emotional processing in BPD. One of the first studies was published by Levine et al. [5], who reported lower levels of emotional awareness, less capacity to coordinate mixed valence feelings, lower accuracy of recognizing facial expressions of emotion, and more intense responses to negative emotions compared with nonborderline control individuals. Wagner and Linehan [6], compared with the Levine et al. [5] study, used a higher number of facial expressions and restricted their sample to women exclusively. They reported quite different results on facial expression recognition ability in BPD, and indicated an absence of any deficits in the recognition of basic emotions in others. On the contrary, in this study, women with BPD even showed a tendency toward heightened sensitivity on recognition of fear. In a study using affective stimuli related to the characteristic fear of being abandoned, BPD patients self-ratings indicated significantly more intense affective experiences in individuals with impulsive selfharming behavior (most of whom met diagnostic criteria of BPD), compared with other types of personality disorders and healthy women volunteers [7]. In the past 2 years, several neuropsychologic tasks, which focus on the influence of emotions on information processing, have been applied. Korfine and Hooley [8]
Address Department of Psychiatry and Psychotherapy, Aachen University, Pauwelstrasse 30, Aachen D-52057, Germany. E-mail: sherpertz@ukaachen.de Current Psychiatry Reports 2003, 5:2327 Current Science Inc. ISSN 1523-3812 Copyright 2003 by Current Science Inc.

In the field of personality disorders, borderline and antisocial types are associated with emotional dysfunctioning. In borderline personality disorder (BPD), the hypothesis of emotional hyperresponsiveness can be supported by several experimental studies that suggest highly intensive and slowly subsiding emotions to primed and non-primed stimuli, as well as by data showing biased information, which processes in the context of emotions. In addition, the first neuroimaging data suggest that limbic hypersensitivity is a neurofunctional correlate of emotional vulnerability in BPD. In antisocial psychopathic personality disorder, data confirm the theory of emotional detachment, subsuming fearlessness, and, beyond that, emotional indifference to appetitive stimuli. Because of a fundamental dysfunction in the amygdala, psychopathic individuals appear to use alternative cognitive operations of processing affective material to compensate for the absence of appropriate limbic input, which normally provides prompt information about the affective characteristics of stimuli.

Introduction
Affective responses are one of the main psychologic mechanisms through which humans interact with their environment. There are remarkable inter-individual differences in quality and intensity of affective responses, which combine to produce a characteristic pattern. This pattern influences mood regulation and further basic features of normal and abnormal personality functioning, such as the organization of social relationships and impulse control. In the field of personality disorders, borderline personality disorder (BPD) and antisocial personality disorder (APD), in particular, are associated with emotional dysfunctioning. Therefore, literature over the past years is mostly concerned with these personality disorders. In BPD, empiric research on emotional processing has no long tradition, whereas in APD, researchers find rich psychophysiologic work going back to the 1960s and also some neuroimaging studies from recent years.

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used a directed forgetting paradigm. This design requires participants to view stimuli, some of which they are instructed to remember and some they are instructed to forget [9]. They are then tested on to-be-remembered and to-be-forgotten stimuli. Participants were exposed to three types of wordsborderline (salient negative themes), neutral, and positive. Borderline personality disorder patients recalled significantly more of the borderline words from the to-be-forgotten condition than did control individuals, which suggests a failure to inhibit rehearsal of emotional information, which is a process that requires extinction of working memory contents. Because neuropsychologic data of the authors group do not support the notion of general cognitive disinhibition in BPD (Kunert et al., Unpublished data), deficient inhibitory mechanisms in the presence of affectively valenced stimuli may suggest intrusion of affect into information processing in BPD individuals. Arntz et al. [10] reported attentional bias to negative emotional stimuli in the emotional Stroop test that was not restricted to borderline-specific word material, but could be generalized to aversive emotional words. However, interference caused by supraliminally presented emotional words was not specific of BPD, but was also found in subjects with cluster C personality disorder, which suggests hypervigilance for any emotionally negative stimuli in a variety of personality disorders. Results of a study by Startup et al. [11] suggest that over-general autobiographic recall is negatively correlated with frequency of parasuicide among patients with BPD, which probably helps borderline individuals avoid distressing memories. On the whole, data confirm the theory of emotional hyperresponsiveness in BPD, which leads to biased information processing in the context of emotions. Biologic correlates of emotion Psychophysiologic data did not give evidence for autonomous hyperresponsivity to emotional stimuli in BPD. Neither male criminals with BPD [12] nor borderline women from a clinical setting [13,14] showed increased autonomic responses to standardized emotional slides. On the contrary, women showed decreased electrodermal responses compared with patients with avoidant personality disorder and control individuals. Data suggest that peripheral and central correlates of emotion may dissociate from each other and that decreased autonomic response may be related to a dissociative state in BPD patients while viewing emotional slides. So far, only one functional neuroimaging study has been published in BPD using an emotional provocation design [15]. This functional MRI (fMRI) study made use of standardized emotional stimuli taken from the International Affective Picture System [16]. When subjects were viewing negative rather than neutral pictures, data revealed significantly stronger bilateral blood oxygenation leveldependent fMRI signal intensity changes in the amygdala of six women with BPD compared with six control women. The BPD group

and control group also showed differences in the activation pattern of brain areas that process visual information. In BPD patients, but not in control individuals, a strong activation was found in the fusiform gyrus, which is a part of the associative visual cortex that is directly interconnected with the amygdala and may reflect the modulation of the perceptual cortex through the amygdala in order to strengthen perception to emotionally relevant environmental stimuli [17]. Because heightened amygdala activation is also found in mood (for review, see [18]) and anxiety disorders (for review, see [19]), it is important to mention that the patients included in this study had no current diagnoses of major depression or any anxiety disorder, including post-traumatic stress disorder. Further studies are needed to clarify the nosologic specificity of neuroimaging data; amygdala hypersensitivity may be a neurofunctional correlate of a basic personality dimension, such as affective instability or neuroticism, than of a specific categoric diagnostic entity. In addition, future research has to focus on circuitry rather than single brain structures. A dysfunctional circuitry with the amygdala and the prefrontal cortex, as the two key components, has already been suggested as the biologic basis of emotional dysregulation in BPD [20], that is, enhanced amygdala activation may be related to a deficiency of prefrontal top-down control. Whether the finding of decreased volumes of the hippocampus and the amygdala in women with BPD [21] fits into this theory is of further interest. Limbic hyperreactivity suggested by neuroimaging data challenges psychotherapeutic strategies, which strengthen cognitive processing of emotions by learning skills that help to improve the identification and labeling of emotional experiences or by establishing senseful connections between life-history and maladaptive emotional responses. The role of therapy may be to allow the cortex to establish more effective and efficient synaptic links with the amygdala [22]. A fundamental target of dialectical behavior therapy is problems with regulating affects in BPD [2]. Therefore, controversial behavior therapy interventions focus on the various elements of the emotion response system, including emotional experiences, cognitions, expressive-motor behavior, and action tendencies [23]. Specific techniques include exposure-based procedures, emotional validation, and the enhancement of capacities such as paying attention to experience, shifting attention away from cues associated with negative emotion, and learning to observe, describe, and understand the function of emotions.

Emotional Detachment and Psychopathology

Abnormal or deficient emotional responsiveness is considered to be the hallmark of psychopathology, which is a subtype of APD, with a particularly bad legal prognosis. Psychopathic individuals show emotional detachment from and indifference to the feelings of others; they do not display any remorse or shame, nor do they experience affection or love [14,24]. Fearlessness and callousness are

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thought to result from deficient emotional learning and poor conditioning processes, in particular. Findings from psychopathic individuals cannot be generalized to APD, in general, because the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition category is widely restricted to the description of criminal behavior and hardly operationalizes specific character features. Data from psychophysiology There is a known continuity between behavioral problems in childhood and adult APD [25]. In a review published by Raine [26], low resting heart ratea valid parameter of autonomic underarousalwas reported to be the best replicated and diagnostically specific biologic correlate of antisocial behavior in children and adolescents; only poor concentration was a further independent predictor of violence. Finally, high heart rate with electrodermal hyperresponsiveness protects against criminal development [27]. Herpertz et al. [15] reported decreased electrodermal responses to aversive startling stimuli in 8- to 13-year-old boys with a comorbid condition of attention deficit/hyperactivity disorder and conduct disorder compared with children with attention deficit/hyperactivity disorder alone and normal control children. Decreased autonomous response, which is also a consistent finding in adult APD, may reflect insensitivity toward potentially frightening events, and may interfere with danger anticipation and passive avoidance learning [28,29]. In addition to attenuated autonomic arousal and reactivity, startle methodology has gained importance in the field of APD. The startle probe is an aversive stimulus that elicits a defensive withdrawal response (one component is the eye-blink reflex). An absence of the typical augmentation of startle response during exposure to aversive fearful stimuli was reported in psychopathic individuals [30,31]. Herpertz et al. [15] found an abnormal startle response pattern not only in the context of fear-related stimuli, but in relation to any kind of emotional stimulus, whether it was related to feelings of fear or threat or to sympathy with others. In the Herpertz et al. [15] study, psychopathic individuals did not only show an absence of startle potentiation when viewing aversive slides, but psychopathic individuals were also characterized by a deficient startle inhibition in relation to stimuli inductive of an appetitive response. In addition, nearly 40% of the psychopathic individuals in the Herpertz et al. study did not show any startle response to 100-decibel startling tones. On the whole, startle data suggest a prominent fearlessness to aversive, frightening events, but beyond that, a general deficit of psychopathic individuals in processing affective information. Data from psychologic tasks Blair et al. [32] developed study designs to test their theory of a violence inhibition mechanism, which refers to evolutionary roots of mechanisms of controlling aggression that show the termination of aggressive attacks when signals of

submission are exhibited. In a recently published study [32], the sensitivity of children with psychopathic tendencies to facial expressions was investigated. In the Emotional Expression Multimorph Task, facial expressions start out looking neutral, but then slowly, through 20 successive frames of increasing intensity, they change to reveal one of the six basic emotions. Data indicated that children with psychopathic tendencies required more stages before they successfully recognized sad expressions, and even when the fearful expressions were at full intensity, they were significantly more likely to mistake them for another facial expression. These data support those of the same research group, indicating that children and adults with psychopathic tendencies make more errors in recognizing fearful and sad expressions than normal control individuals do [32]. Further information on the processing of emotional stimuli comes from studies that make use of neuropsychologic tasks that focus on the processing of semantic emotional material. Antisocial personalities were found to have difficulty in processing emotional information, because they show shorter decision time and larger event-related brain potentials when processing semantic emotional material [33,34], and they do no better in remembering the central details of a negative than of a neutral slide [35]. Data from functional neuroimaging In recent years, functional imaging studies have been performed to identify neurofunctional correlates of deficient emotional processing in psychopathic personalities. Kiehl et al. [36] found decreased activity in the amygdala-hippocampal formation, in the parahippocampal gyrus, ventral striatum, and in the anterior and posterior cingulate gyri compared with non-psychopathic criminals and non-criminal control individuals in an affective memory task subsuming encoding, as well as recognition of emotional and non-emotional words. However, they showed greater activation for affective than for neutral stimuli in the bilateral inferior lateral frontal cortex, which is associated with semantic and decision-making processes. The authors concluded that psychopathic individuals use non-limbic cognitive strategies to process affective material. From an older study, which used single photon emission computed tomography methodology, Intrator et al. [37] reported increased relative cerebral blood flow in the bilateral amygdala-hippocampal formation in psychopathic individuals in a lexical decision task. This finding reflected a higher amount of effort needed by psychopathic individuals to perform the task successfully. These studies suggest that psychopathic individuals use alternative cognitive operations of processing affective material to compensate for the absence of appropriate limbic input that normally provides prompt information about the affective characteristics of stimuli. Increased activation in the amygdala (besides the dorsolateral prefrontal cortex) was found by Schneider et al. [38] in antisocial, psychopathic personalities, compared with control individuals, when a

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standard aversive conditioning procedure was applied. Activation was increased during acquisition, that is, making the emotional association between a nasty smell and faces with an emotionally neutral expression. According to the authors, this unexpected finding may reflect a greater effort of the antisocial individuals to learn the associations forged in aversive conditioning experiments. Emotion and antisocial behavior Concluding from studies that have dealt with the affective domain in psychopaths, emotional deficiency may predispose to violence in the following two ways: 1) fearlessness and poor conditioning implicates a failure to review the harmful consequences of ones actions leading to a deficit of avoidance behavior; and 2) emotional detachment prevents experiencing the fear, empathy, guilt, and remorse that naturally inhibit the acting out of violent impulses. Specific abnormalities in the functional anatomy of the brain may, however, be related to a fundamental dysfunction within the amygdala that plays a critical role in assigning emotional significance to sensory input and mediating rapid responses to fearful environmental stimuli (for review, see [22]). However, psychopathology may be related to a dysfunctional orbitofrontal cortex, which is the area necessary for knowledge acquisition that provides a basis for moral and social behavior. Patients with early acquired orbitofrontal damages exhibited behavioral deficits that were accompanied by an absence of factual knowledge related to feelings engendered by similar situations in the past and, thus, to the probable reward value of behavior [39]. Understanding the neurobiologic basis of emotional functioning in psychopathic individuals may help to gain new ideas for therapy. Current knowledge suggests that psychotherapeutic interventions based on conditioning or learning empathy for others may not be successful in the psychopathic subtype of APD. Following review of psychotherapeutic approaches to aggressive and violent patients by Alpert and Spillmann [40], the authors of this paper conclude that the focus should lie on a detailed assessment of the aggressive acts, their antecedents, accompanying cognitions, as well as emotions and their consequences. Early identification of endangered children could prevent unfavorable outcome by early environmental enrichment that, for example, was associated with long-term increases in psychophysiologic response style [41].

and improved measuring of emotion are promising. The majority of studies have dealt with issues of emotional or cognitive processing; it is an interesting topic for the future how emotion and cognition interact, for example, how emotions disturb basic perceptual, attentional, and memory functions so that adaptive self-regulation cannot be attained [42]. Furthermore, prospective studies that continuously observe the development of emotional processing from childhood to early and late adulthood are needed, because emotional processing appears closely related to temperament that is thought to be stable, but at the same time is modulated through maturation processes.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: Of importance Of major importance
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Conclusions
Although issues of emotional disturbances are at the heart of the current concept of personality disorder, a precise analysis of the characteristics and peculiarities of emotional processing in the various personality disorders and their biologic underpinnings is still in its infancy in this field. Future work will be facilitated by rapid progress in experimental laboratory research; particularly, the combined use of brain imaging, elaborate performance tasks,

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28.