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Interpersonal functioning in borderline personality disorder: A

systematic review of behavioral and laboratory-based assessments


Sophie A. Lazarus
a,
, Jennifer S. Cheavens
a
, Francesca Festa
b
, M. Zachary Rosenthal
c
a
Department of Psychology, The Ohio State University, USA
b
School of Education, The Ohio State University, USA
c
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, USA
H I G H L I G H T S
Interpersonal dysfunction is central in borderline personality disorder (BPD).
We highlight objective measures of areas of potential impairment in those with BPD.
Those with BPD have heightened emotional reactivity to interpersonal stressors.
Individuals with BPD show impairment in trust and cooperation.
We offer suggestions for future research.
a b s t r a c t a r t i c l e i n f o
Article history:
Received 6 May 2013
Revised 18 January 2014
Accepted 23 January 2014
Available online 5 February 2014
Keywords:
Borderline personality disorder
Interpersonal functioning
Social cognition
Trust/cooperation
Parenting
Interpersonal aggression
It is widely accepted that interpersonal problems are a central area of difculty for those with borderline
personality disorder (BPD). However, empirical elucidation of the specic behaviors, or patterns of behaviors,
characterizing interpersonal dysfunction or dissatisfaction with relationships in BPD is limited. In this paper,
we reviewthe literature on interpersonal functioning of individuals with BPDby focusing on studies that include
some assessment of interpersonal functioning that is not solely self-report; that is, studies with either behavioral
laboratory tasks or manipulation of interpersonal stimuli in a controlled laboratory setting were included. First,
we review the literature relevant to social cognition, including perceptual biases, Theory of Mind/empathy,
and social problem-solving. Second, we discuss research that assesses reactivity to interpersonal stressors and
interpersonal aggression in BPD. Next, we review the literature on trust and cooperation among individuals
with BPD and controls. Last, we discuss the behavior of mothers with BPD in interactions with their infants.
In conclusion, we specify areas of difculty that are consistently identied as characterizing the interpersonal
behaviors of those with BPD and the relevant implications. We also discuss the difculties in synthesizing this
body of literature and suggest areas for future research.
2014 Elsevier Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
2. Characterization of interpersonal dysfunction in BPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
2.1. Social cognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
2.1.1. Perceptual biases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
2.1.2. Theory of Mind (TOM) and empathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
2.1.3. Social problem-solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
2.2. Reactivity to interpersonal stressors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
2.3. Interpersonal aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
2.4. Lack of cooperation/trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
2.5. Behavior within motherchild interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Clinical Psychology Review 34 (2014) 193205
Corresponding author at: 181 Psychology Building, 1835 Neil Avenue, Columbus, OH 43210, USA.
E-mail address: lazarus.15@osu.edu (S.A. Lazarus).
http://dx.doi.org/10.1016/j.cpr.2014.01.007
0272-7358 2014 Elsevier Ltd. All rights reserved.
Contents lists available at ScienceDirect
Clinical Psychology Review
3.1. Future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Appendix A. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
1. Introduction
Borderline personality disorder (BPD) is a serious public health prob-
lem that poses considerable challenges for mental health professionals,
those suffering from the disorder, and their families. Individuals with
BPD disproportionately present for treatment in both inpatient and out-
patient clinics relative to many other disorders, leading to high
rates of health care utilization and associated costs (Skodol et al.,
2005). Although the diagnostic criteria for BPD (American Psychiatric
Association, 2013) include dysfunction across a wide range of neurobe-
havioral systems, including emotional expression (e.g., marked reactivi-
ty), behavioral inhibition (e.g., impulsivity), cognition (e.g., paranoia or
dissociation when acutely distressed), and interpersonal functioning
(e.g., fear of abandonment), disturbed interpersonal relationships are in-
creasingly being recognizedas central to understanding the impairments
and psychological distress associated with the disorder (Gunderson,
2007).
The empirical investigation of interpersonal functioning in BPD
occurs in the context of a rich theoretical history. Several interrelated
psychodynamic and psychoanalytic theories explain interpersonal
disturbances in BPD. These theories emerged as clinicians observed
the centrality of interpersonal problems for individuals with BPD and
endeavored to explain the origin of pathological and extreme interper-
sonal behavior, such as suicidal behaviors in response to interpersonal
conict or rejection. While these theories generally focus on problems
in early relationships and caregiving experiences, each has a somewhat
unique explanation for the development of dysfunctional interpersonal
behaviors in adulthood.
In one such interpersonal theory of BPD, object relations theorists
(e.g., Jacobson, 1964; Kernberg, 1980; Klein, 1957) posit that self-
other representations form in early relationships, particularly between
the infant/child and the primary caregiver, and that these cognitive
representations play a central role in personality development. Some
have argued (e.g., Westen, 1991) that the emotions and expectations
attached to these representations are critically important determinants
of functioning in interpersonal relationships as dyads are linked by the
affective valence of the representations. For example, according to
Clarkin, Lenzenweger, Yeomans, Levy, and Kernberg (2007), individuals
with BPD have representations of self and others that are affectively
split (i.e., positive and negative representations) and lack integration
(i.e., unstable representations). Thus, object relations theorists would
predict polarized interpretations of others (e.g., dichotomous thinking),
which are heavily inuenced by the affect linking the dyad within the
particular interaction.
Another way of understanding the interpersonal behavior associat-
ed with BPD is through the lens of attachment theory. Attachment
theorists posit that children, based mostly on interactions with primary
caregivers, develop internal models of the self and others that guide
expectations and beliefs in relationships, particularly in times of stress
(Bowlby, 1973). Secure attachment with the caregiver allows the child
to develop and maintaina coherent and positive sense of self and expec-
tations for responsive and caring behavior from others. In contrast, BPD
is typically characterized by disturbed attachment and representations
of the self and others that are inconsistent and negative (Agrawal,
Gunderson, Holmes, & Lyons-Ruth, 2004). According to Fonagy,
Target, Gergley, Allen, and Bateman (2003), the development of secure
attachment hinges on caregivers' abilities to understand their own and
others' minds and help the child develop this capacity (i.e., provide a
scaffolding for mentalization). A failure to develop the ability to
perceive and interpret behavior based on underlying mental states
(mentalization) may lead to difculty interpreting and under-
standing interpersonal experiences, especially in contexts where
the attachment system is activated (i.e., under conditions of perceived
threat). Accordingly, this theory predicts that decits in mentalization
associated with maladaptive attachment account for the interpersonal
dysfunction among individuals with BPD.
Linehan's biosocial model (Linehan, 1993) is an alternative account of
the development of interpersonal problems in BPD. According to this
model, an underlying biological vulnerability to emotional dysregulation
(i.e., high sensitivity and reactivity to emotional stimuli, slow return to
baseline after emotional arousal) transacts with environmental stressors
(i.e., invalidation) to contribute to emotional and interpersonal impair-
ments. The transactional interplay between these biological and so-
cial factors is believed to adversely inuence the development of
one's sense of self and other, disrupting the development of healthy
relationships. Thus, inthis model, disrupted(or less thanideal) relation-
ships function as both a risk factor for the development of BPD and a
consequence of the disorder. The consistent undermining of one's inter-
nal experience (i.e., invalidation) may interfere with healthy interperson-
al relations by contributing to a disturbed learning history for close
relationships, creating anoverreliance onothers' opinions andindications
of worth, and encouraging dichotomous (i.e., all good or all bad) thinking
about others.
Consistent with interpersonal theories of BPD, evidence that inter-
personal functioning is a major area of concern for those with BPD can
be found across converging areas of empirical research. For example,
factor analytic studies indicate that disturbed interpersonal relations
represent a key factor underlying the variance across BPD symptoms
(Sanislowet al., 2002). Further, individuals with BPDoften report great-
er problems with interpersonal functioning compared to healthy con-
trols (e.g., Bouchard, Sabourin, Lussier, & Villeneuve, 2009).
Additionally, some of the most serious outcomes related to BPD, such
as self-injury and suicide, frequently occur in interpersonal contexts
(e.g., Brodsky, Groves, Oquendo, Mann, & Stanley, 2006; Brown,
Comtois, & Linehan, 2002) and are related to problems with social ad-
justment (Soloff & Fabio, 2008).
Prospective studies suggest that improvement in interpersonal
functioning occurs more gradually in BPD than in several other Axis II
disorders (Choi-Kain, Zanarini, Frankenburg, Fitzmaurice, & Reich,
2010; Skodol et al., 2005). In fact, certain interpersonal symptoms
such as negative affect when alone, fear of abandonment, discomfort
with care, and dependency are extremely slow to remit, with 15% to
25% of individuals with BPD who exhibited these symptoms at baseline
failing to show improvement at 10-year follow-up (Choi-Kain et al.,
2010). Further, remission from the disorder is often related to positive
interpersonal events, such as entering a stable relationship (Links &
Heslegrave, 2000).
Thus, impairment in interpersonal functioning: (a) is theoretically
and diagnostically central to BPD, (b) is associated with self-injurious
behavior and other adverse clinical outcomes, (c) plays an important
role in the prognosis and course of BPD, and (d) is reported by those
with BPD as signicantly problematic. The evidence clearly suggests
that interpersonal functioning in BPD is often meaningfully impaired.
What is less clear, based on the existing body of research, is how to
precisely characterize the various interpersonal impairments in BPD.
In recent years, the pace of empirical research examining problems
with interpersonal functioning in BPD has accelerated. The eld has
moved from a primary reliance on cross-sectional self-report to more
sophisticated designs using prospective methodologies and more eco-
logically valid assessments of interpersonal behavior. The use of such
194 S.A. Lazarus et al. / Clinical Psychology Review 34 (2014) 193205
laboratory-based methods of measurement has much to offer the study
of interpersonal functioning in BPD. When characterizing interpersonal
impairments in those with BPD, it is useful to have multiple methods of
assessment for specic behaviors to identify the basic processes that
might differentiate them from others. This also affords the opportunity
to assess how self-reported interpersonal problems align with
laboratory-based measures of these same difculties. In addition, as-
sessments that more closely approximate real world interpersonal set-
tings can advance an empirical understanding of the interpersonal
contexts (e.g., social rejection) that elicit BPD criterion behaviors
(e.g., hostility/anger). Another advantage of focusing on behavior in
specic contexts is that this approach mitigates some of the challenges
associated with retrospective self-reports of general interpersonal
functioning (e.g., self-report biases and inaccuracies), which will be
discussed below. Put simply, these objective and performance-based
measures, when used in conjunction with traditional self-report and
interview measures, may advance the precision with which we under-
stand how to characterize interpersonal problems in BPD.
There have been fewattempts to reviewand synthesize the existing
research base on interpersonal functioning in BPD (for exceptions, see
Bornstein, Becker-Matero, Winarick, & Reichman (2010) for a review
of dependency in BPD and Agrawal et al. (2004) for a review of attach-
ment in BPD). To our knowledge, no reviews have focused solely on
behavioral and laboratory assessments of interpersonal functioning in
BPD. In an attempt to maintain a focus on objective measures of the
interpersonal functioning of those with BPD, we included only empirical
studies that a) sampled individuals with BPD symptoms or diagnoses
and b) included objective measures of either interpersonal behavior
or responses to interpersonal assessments in controlled laboratory
settings. We included ndings derived from subjective responses to
interpersonal stimuli in laboratory behavioral paradigms; however,
studies that included only self-report measures were excluded for two
reasons. First, self-report measures tend to assess habitual responding
or average states and we were interested in specic instances of inter-
personal behavior. Second, there is evidence to suggest that people with
BPD have disproportionate access to negative memories and are likely
to hold negative evaluations of themselves and others (Baer, Peters,
Eisenlohr-Moul, Geiger, & Sauer, 2012). As such, relying solely on self-
reports of interpersonal functioning may obscure potentially important
variations in interpersonal behaviors.
In this review, we summarize the research in an attempt to charac-
terize difculties with interpersonal behavior among individuals with
BPD. Our goal is to integrate the existing literature in this area, generate
hypotheses for further study, and stimulate future research focused on
understanding the interpersonal disturbances among individuals with
BPD. Ultimately, as interpersonal difculties in BPD become better
elucidated, the next generation of assessment measures and interven-
tions can be developed to more rapidly and directly target specic
interpersonal problems for individuals with this disorder.
2. Characterization of interpersonal dysfunction in BPD
The existing literature can be organized into several specic areas of
potential impairment. These domains of interpersonal dysfunction,
introducedbelow, provide anatheoretical andempirically-basedframe-
work for the scope of this literature review.
1
The rst, social cognition,
includes studies of perceptual biases, Theory of Mind (TOM), and social
problem-solving. Researchoninterpersonal perceptual biases addresses
the question of whether individuals with BPD can be characterized by
dysfunctional appraisals of others. TOM research examines the ability
of those with BPD to recognize and understand interpersonal situations,
including the anticipated emotional reactions of others. Social problem-
solving research aims to examine whether individuals with BPD
demonstrate impairments in problem-solving skills or cognitive exibili-
ty when encountering social problems. Thus, tests of social cognition
would suggest that one way to characterize interpersonal dysfunction
in BPD is via differences in interpretations of interpersonal situations.
A second domain of potential interpersonal dysfunction in BPD is
reactivity to interpersonal stressors. In these studies, researchers use
laboratory biobehavioral methods in an attempt to characterize differ-
ent patterns of reactivity among individuals with BPD and controls to
both interpersonal and non-interpersonal stimuli. Stronger reactions
to interpersonal stimuli, compared either to non-interpersonal stimuli
or controls, might suggest that heightened negative emotion in inter-
personal situations characterizes BPD. The third domain of interperson-
al impairment addressed in this review is interpersonal aggression.
Interpersonal aggression, particularly in response to rejection cues,
might increase the probability of unstable or otherwise problematic
relationships for those with BPD. The fourth domain of interpersonal
impairment discussed examines research aimed at identifying observ-
able differences in trust and cooperation between those with BPD and
others. If BPD is characterized by a lack of trust and cooperation, it is
likely to result in an impaired ability to participate in and make full
use of social networks and relationships. Last, we consider a relatively
recent body of research that uses laboratory-based interactions
between mothers and infants to identify how women with BPD may
differ from others in behavior towards their children. If women with
BPD are indeed characterized by specic patterns of interpersonal
behavior with their children, this information could inform models of
both the transmission and maintenance of BPD features.
2.1. Social cognition
Successfully navigating interpersonal interactions is a complex task
which relies on a coordinated set of processes that allow people to
make sense of their social environments through understanding their
own emotions, as well as the emotions and interpersonal motivations
of others. Referred to as social cognition (Fiske & Taylor, 1991), this
set of processes encompasses other constructs including perceptual
biases, TOM/empathy, and social problem-solving.
Inherently related to social cognition is the ability to correctly
identify the emotions of others. In fact, emotion recognition is central
to the ability to accurately perceive, interpret, and respond appropriate-
ly to social cues. Studies examining emotion recognition in BPD high-
light how difculties in interpersonal relationships may be related to
less accurate detection and identication of facial affect in others
(Bland, Williams, Scharer, & Manning, 2004; Levine, Marziali, & Hood,
1997; Merkl et al., 2010; Unoka, Fogd, Fzy, & Csukly, 2011). Indeed,
several research groups found that individuals with BPD were less accu-
rate in recognizing facial expressions of emotion displayed at full intensi-
ty, either neutral or negative, compared to healthy controls (e.g., Levine
et al., 1997). Others have pointed out that the impairment seems to be
limited to recognition and discrimination among negative emotions
(Bland et al., 2004; Guitart-Masip et al., 2009), especially fear and anger
(Unoka et al., 2011). Those with BPD may be more likely to misinterpret
neutral expressions as negative (Dyck et al., 2009) and have poorer
recognition of integrated facial/prosodic emotions when they are
displayed together (Minzenberg, Poole, & Vinogradov, 2006). However,
the results on this topic are mixed. Data from some studies suggest no
impairment in emotion recognition in individuals with BPD or BPD
symptoms compared to healthy controls (Domes et al., 2008; Gardner,
Qualter, Stylianou, & Robinson, 2010) and there is some evidence of
faster accurate responding in those with BPD compared to controls
when detecting emotion in faces morphing from neutral to full expres-
sions (Lynch et al., 2006).
These mixed ndings are difcult to synthesize due to the different
methodologies, facial affective stimuli, the possible inuence of
psychotropic medications, and co-occurring psychiatric problems
across studies. For example, research suggests that those with mood
1
See supplementary information for tables detailing the studies included in each
section.
195 S.A. Lazarus et al. / Clinical Psychology Review 34 (2014) 193205
(e.g., Bistricky, Ingram, & Atchley, 2011) and anxiety (e.g., Shin et al.,
2005) disorders demonstrate dysfunctional processing of facial affective
cues. Given the high rates of co-occurring mood and anxiety disorders
(e.g., 96.3% and 88.4%, respectively; Zanarini et al., 1998) among those
with BPD, it is extremely difcult to determine whether decits in facial
affect recognition characterize BPD, specically, or are better accounted
for by comorbid symptom disorders. In addition, there is evidence that
anti-depressants enhance selective attention towards positively valenced
stimuli in depressed adults (Wells, Clerkin, Ellis, & Geevers, 2014), and
anxiolytic interventions for social anxiety attenuate amygdala reactivity
to angry and fearful facial expressions (Phan et al., 2013). It is possible
that use of psychotropic medications by those with BPD may inuence
facial affect recognition and the direction of the inuence (e.g., faster/
slower response, increased/decreased attention to threat) may depend
on a complex interaction among BPD status, medication regimen,
and specic comorbid symptom disorders. Accordingly, it is important
to account for current psychotropic medication use and comorbid disor-
ders when attempting to reconcile contradictory ndings in the area of
facial affect recognition.
Another possible explanation for the discrepancies in ndings, sug-
gested by Daros, Zakzanis, and Ruocco (2013), is related to an interaction
between the intensity of the displayed facial emotion and baseline
emotional arousal. For example, when viewing faces of lower intensity,
high baseline emotional arousal may enhance facial emotion detection
abilities, whereas when emotions are presented at full intensity, the
same baseline arousal may actually interfere with accurate perception.
This would help explain earlier detection of facial emotion (Lynch
et al., 2006) and also impairment at full presentation that is generally
specic to discrimination among negative emotions.
Studies that examine the ability to decode mental states from pic-
tures of only the eye area (Reading the Mind in the Eyes Test, RMET;
Baron-Cohen, Wheelwright, Hill, Raste, & Plumb, 2001) in individuals
with BPD also yield somewhat mixed ndings. While in two studies
(Fertuck et al., 2009; Scott, Levy, Adams, & Stevenson, 2011) BPD was
related to more accurate perception of mental states, another study
(Preiler, Dziobek, Ritter, Heekeren, & Roepke, 2010) found no differ-
ence between women with BPD and healthy controls. Fertuck et al.
(2009) found that averaged across conditions, the BPD group was
superior to the healthy control group on the mental state discrimination
task; when the conditions were examined separately, the BPD group
advantage was evident for positive and neutral stimuli, but not for
negative stimuli. However, when controlling for severity of depressive
symptoms, participants with BPD were superior to healthy controls
only on the total score of RMET, suggesting that inclusion of depressive
symptoms weakens the effect of BPD status on RMET performance.
Scott et al. (2011) came to the same conclusion as Fertuck et al.
(2009) but found the opposite pattern at the level of emotion valence;
the high BPD feature group responded more accurately than the low
BPD feature group but only for negatively valenced stimuli. Taking
these two studies together, it is possible that the interaction between
baseline arousal and intensity of the emotional stimuli may again help
to explain the inconsistencies. If individuals with BPD features (i.e.,
Scott et al., 2011) have lower levels of baseline emotional arousal than
those with diagnosed BPD(i.e., Fertuck et al., 2009) and positive or neu-
tral emotions can be assumed to be less emotionally arousing for those
with BPD and related features, Daros et al.'s (2013) hypothesis might
explain the superior performance of the BPD feature group in the nega-
tive valence condition and the BPD disorder group in the positive and
neutral conditions.
The results fromthese studies indicate that BPD is not related to any
clear decits in the perception of mental states fromjust the eye region,
and may actually be associated with increased accuracy for particular
stimuli. Replication of these results with both clinical and subclinical
samples would help clarify the impact of valence and severity of BPD
symptoms on mental state perception. Findings of less accurate facial
recognition may suggest that individuals with BPD are distracted by
increasing amounts of information provided by the entire facial region,
which is consistent with ndings that those with BPD perform worse
when decoding combined facial and prosodic information (Minzenberg
et al., 2006). It is also possible that an increase in emotional information
leads to higher arousal, which may moderate the effect of increased com-
plexity of stimuli on accuracy. Given that we typically have an abundance
of facial and extralinguistic information in day-to-day life, it is important
to continue this research examining whether individuals with BPD may
face a disadvantage in real-world social interactions.
2.1.1. Perceptual biases
Related to facial emotion perception in BPD is the issue of whether
those with BPD have more negative and extreme views of others com-
pared to healthy individuals and those with other personality disorders
(PDs). In order to examine perceptual biases in BPD, in several studies
(Arntz & Veen, 2001; Sieswerda, Barnow, Verheul, & Arntz, 2013;
Veen &Arntz, 2000) Arntz and colleagues asked participants to evaluate
actors in lm clips to assess whether BPD is related to more extreme or
negative ratings of others. Veen and Arntz (2000) found that when
accounting for the contribution of other Axis II disorders and self-
reported emotional responses to clips, individuals with BPD had more
extreme categorizations of others (i.e., responses further from zero on
a visual analog scale of opposing qualities) for situations with BPD-
specic themes (e.g., rejection, abandonment) than individuals with
Cluster C PDs or healthy controls. However, Sieswerda et al. (2013)
found no evidence of more extreme categorization of others by individ-
uals with BPD compared to controls. Taking these studies together,
individuals with BPD and Cluster C PDs had stronger self-reported
emotional responses to lms (Veen & Arntz, 2000) and provided less
complex evaluations of the actors in the clips (Arntz & Veen, 2001).
Individuals with BPDalso had a tendency to rate actors more negatively
than healthy controls (Sieswerda et al., 2013) and those with Cluster C
PDs (Arntz & Veen, 2001). There are at least two potential explanations
for the discrepancy in the dichotomous thinking ndings. First, the con-
trol group in the Sieswerda et al. (2013) study had higher dichotomous
thinking scores than the control group in the Veen and Arntz (2000)
study; thus, it is possible that the control group in the Sieswerda et al.
(2013) study had more problematic interpersonal processing than
would be representative of healthy controls in general. Second,
Sieswerda et al. (2013) found that severity of childhood sexual abuse
was associated with dichotomous thinking and this association was
not tested in the Veen and Arntz (2000) study. This highlights the
importance of including measures of potential moderators of the
relationship between BPD and interpersonal functioning in order to de-
termine for whom and under what conditions interpersonal difculties
may arise.
Performance-based projective measures of object relations have
been used to assess possible biases in how those with BPD view others.
On these measures, individuals with BPD have more malevolent repre-
sentations of others, lower capacity to invest emotionally in relation-
ships (Segal, Westen, Lohr, Silk, & Cohen, 1992), and less mature/
balanced investment in relationships than those with MDDand healthy
controls (Westen, Lohr, Silk, Gold, &Kerber, 1990). Further, among indi-
viduals with BPD, those with non-suicidal self-injury (NSSI) had more
negative expectations of treatment fromothers and poorer understand-
ing of social causality of interpersonal interactions than those without
concomitant NSSI (Whipple & Fowler, 2011). Together, these results in-
dicate that individuals with BPDare more negative in the way they view
others and in their expectations for relationships than controls. Further,
more severe BPD symptoms, as indicated by the presence of NSSI, may
be related to more extreme negative expectations in relationships.
In contrast to these studies, Tragesser, Lippman, Trull, and Barrett
(2008), using a vignette design, found that BPD features were not asso-
ciated with more negative perceptions of a teaser or more negative at-
tributions for teasing behavior. This is despite the fact that BPD features
were related to the predicted experience of more negative affect in
196 S.A. Lazarus et al. / Clinical Psychology Review 34 (2014) 193205
response to imaginal teasing. In light of the clear differences in methodol-
ogies used, it is difcult to draw conclusions about the diverging pattern
of ndings between this study and the studies that reported perceptual
biases in BPD. One explanation for the inconsistency is that reading
about a hypothetical situation is less emotionally evocative than viewing
video clips, as in the Arntz and Veen (2001), Veen and Arntz (2000), and
Sieswerda et al. (2013) studies. It is also possible that individuals with
BPD features perceive teasing less negatively than other interpersonal
behaviors (e.g., abandonment). Additionally, the participants in the
Tragesser et al. (2008) study had elevated BPD features as opposed to
diagnoses of BPD (as in the other studies). It is possible that perceptual
biases are more pronounced among individuals meeting full criteria for
BPD than in college students with subthreshold BPD features.
2.1.2. Theory of Mind (TOM) and empathy
Researchers have also examined whether individuals with BPDhave
impairments related to understanding social cues, including reactions of
others. Specically, it is posited that individuals with BPD have decits
in TOM abilities, or one's ability to understand and correctly interpret
the mental states that underlie other people's observable behaviors
(Fonagy & Target, 1996), which interfere with successful social interac-
tions. Several studies have beenconductedthat assess participants' ability
to understand the mental states of others with stories and movie clips
depicting social interactions. For example, Arntz, Bernstein, Oorschot,
and Schobre (2009) found no evidence of TOM decits in individuals
with BPD when inferring the thoughts, intentions, and feelings of
characters in standardized stories of nuanced interpersonal behaviors
(e.g., white lies, persuasion, and sarcasm). Harari, Shamay-Tsoory,
Ravid, and Levkovitz (2010), however, found that individuals with
BPD performed worse than controls on cognitive (i.e., ability to detect
the speaker's state of knowledge), but not affective (i.e., ability to un-
derstand the emotional impact of the statement on the listener) under-
standing of a social faux pas. Preiler et al. (2010) provided further
evidence of TOM decits in BPD using a task in which participants
viewed a movie of people interacting in various social contexts, such
as a dinner party, and throughout the video were asked to interpret
the characters' mental states. When compared to healthy female
controls, women with BPD showed poorer recognition of emotions,
thoughts, and intentions of the characters. Thus, when using stories
and movies, there is some evidence that individuals with BPD have im-
pairments in TOM abilities. However, it may be important to differenti-
ate between cognitive and affective abilities. Affective understanding
may be more akin to empathy, while cognitive understanding involves
anunderstanding of norms, intentions, and anticipated outcomes and is
likely to reect a more complex social understanding.
Examining responses to pictures of other people experiencing emo-
tions is another way to assess the ability to understand and empathize
with the emotions of others. New et al. (2012) found no differences
between individuals with BPD and healthy controls in their ratings of
the feelings of people in positive, negative, and neutral interpersonal
pictures. Dziobek et al. (2011) found decits in both cognitive (i.e., infer
mental state) and affective (i.e., rate level of empathic concern) empathy
in those with BPD compared to healthy controls when shown pictures
intended to produce strong emotional reactions (e.g., a child in a war
scene). The authors also found some evidence of differences in neural
activation while viewing emotional pictures. During the cognitive
empathy component of the task, women with BPD, compared to female
healthy controls, had signicantly reduced response in the left superior
sulcus and gyrus, a region which is thought to be related to the ability
to think about others (Saxe & Kanwisher, 2003). During the affective
empathy component of the task, women with BPD, compared to healthy
controls, showedincreasedresponse inthe right middle insular cortex, an
area often associated with emotional reactions to others that are self-
oriented (Jackson, Brunet, Meltzoff, & Decety, 2006). Similarly, in a
study by Mier et al. (2012), individuals with BPD and healthy controls
completed a task assessing affective TOM during an event-related fMRI
design. Although there was no behavioral evidence of decits in TOM in
the BPD group, there were differences in neural activation between the
groups. Whereas healthy controls showed increased activation in
the mirror neuron system with increasing task complexity, the BPD
group exhibited hypoactivation in these areas as well as increased
activation in the left amygdala.
Hypoactivation of areas related to the mirror neuron system could
underlie a learned response to modulate strong emotions related to
increased emotional sensitivity which may be reected in the height-
ened amygdala reactivity. This suggests that individuals with BPD may
rely on affect-dominated processing, which when combined with inad-
equate prefrontal control, may interfere with social processing, espe-
cially under conditions that are complex or involve high emotional
arousal. These ndings offer important insights into possible patterns
of regional neural activation underlying decits in empathy in BPD.
However, it will be important to extend this research using additional
control groups and diverse methods, such as those used to investigate
neural connectivity, in order to more precisely characterize specic
neural mechanisms involved in interpersonal impairments in BPD.
The mixed ndings for affective TOMmay be related to the method-
ology of the studies which differ in several ways that may potentially
impact performance. First, the stimuli differ in their valence and arousal
levels. For example, pictures chosen to be particularly emotionally
evocative (Dziobek et al., 2011) likely elicit differences between those
with BPD and controls, while standardized stories (Arntz et al., 2009)
which are not chosen to be particularly emotional (but rather to depict
social situations) may be less emotionally arousing and allow individ-
uals with BPD to perform well. Second, it is likely that stimuli with
BPD-specic content evoke stronger emotional reactions than more
general stimuli. For example, it is possible that detecting the emotional
impact of a social faux pas is especially relevant to concerns of abandon-
ment and sensitivity to rejection in BPD and this interferes with task
performance. This is opposed to other stimuli that may be less personal-
ly relevant for individuals with BPD, such as that used in Mier et al.
(2012) which asks the participant to match a facial expression with an
emotional intention. Finally, tasks that require more effort on the part
of the participant and/or involve more cognitive load may be more
emotionally arousing and more difcult for individuals with BPD.
Consistent with this, methodology that assesses social understanding
periodically throughout a movie (Preiler et al., 2010) is likely more
challenging than a task that uses static pictures to assess this ability
(Arntz et al., 2009; Newet al., 2012). Given the high emotional sensitiv-
ity in individuals with BPD, these small differences in social stimuli may
have a meaningful impact on performance.
Other researchers have used behavioral laboratory tasks that
simulate interacting with another partner to examine the ways in
which individuals with BPD may differ from others in terms of social
cognition. For example, Wischniewski and Brne (2012) examined par-
ticipants' perceptions of and responses to unfair offers in a versionof the
dictator game wherein individuals with BPD and clinical controls with
no PD observed two other players (i.e., dictator and recipient played
by the computer). Participants could punish the dictator for unfair
offers by taking away money to give to the recipient. Individuals
with BPD were no more (or less) likely to punish the dictator than
participants without a PD; both groups increased punishment in
accordance with the degree of unfairness of the offer, suggesting
that those with BPD are as able to evaluate and respond to observed
unfairness by others. Similarly, Franzen et al. (2011) used a virtual
social exchange game to examine the inuence of emotional cues
and assessment of fairness on the ability to judge a partner's
intentions. BPD and healthy control participants acted as the inves-
tor, deciding how much money to invest in a multi-round trust
game with four different trustees, who varied both in the trustwor-
thiness of their offers and emotional expressions (e.g., neutral or
congruent with the fairness of their offer) throughout the round.
Whereas for the BPD participants, the trustworthiness of the partner's
197 S.A. Lazarus et al. / Clinical Psychology Review 34 (2014) 193205
offer was related to their investment regardless of emotional expres-
sion, for controls, the emotional cues were weighed more heavily than
trustworthiness in investment decisions. This is despite the fact
that the two groups performed comparably on an earlier emotion
recognition task that used the trustees' faces as stimuli, suggesting
that individuals with BPD did not use the emotional information in
evaluating fairness of an offer, even though it was available to them.
This is consistent with the ndings of increased sensitivity or vigilance
to cues of social threat, with participants with BPD attending to the
unfair offers regardless of additional informationprovided by emotional
expression. It also supports the presence of intact affective TOMin BPD,
but differences or decits in cognitive TOM.
Other behavioral laboratory tasks that involve the correct sequenc-
ing of social scenarios also have been used to assess TOM abilities. For
example, Ghiassi, Dimaggio, and Brne (2010) examined the perfor-
mance of individuals with BPD and healthy controls on sequencing of
social scenarios (Brne, 2005) depicting cooperation and cheating and
found no differences between the two groups. However, Schaffer,
Barak, and Rassovsky (2013) found that individuals with BPD scored
lower on the Picture Arrangement subtest from the Wechsler Adult In-
telligence Scale (WAIS-III; Wechsler, 1998) compared to controls and
that performance did not depend on whether or not contextual infor-
mation (i.e., a title for each scene) was provided. Context did, however,
have an impact on response time. When contextual information was
provided, the BPD group was slower to respond than controls (M =
27.3 s and 16.6 s, respectively); however, when contextual information
was not provided, the BPD group responded more quickly than controls
(M = 18.9 s and 24.9 s, respectively). Participants with BPD also per-
formed worse than controls on a test of general social perception (i.e.,
the ability to label facial expressions, voice intonations, and bodily ges-
tures containing social cues). This suggests that those with BPDmay mis-
interpret social cues at relatively basic levels, which then may lead to
difculty integrating social cues and understanding social situations,
resulting in further interpersonal difculties. Although it did not impact
accuracy, contextual information actually impaired the performance of
those withBPDby increasing reactiontime to complete the social percep-
tion task. This may suggest that individuals with BPD are overwhelmed
by contextual interpersonal cues, evenwhensuchcues are designedto fa-
cilitate responding (and do so for those without BPD). Given the decit
in accurately labeling interpersonal cues such as tone of voice and ges-
tures, contextual cues may not serve the anticipated facilitative func-
tions for those with BPD. The differential impact of contextual
information on BPD versus control participants, as well as the neuroim-
aging results from Mier et al. (2012), suggest that although some im-
portant interpersonal information is equally available to individuals
with BPD, this information may be processed or used less effectively.
Consistent with this, Franzen et al. (2011) found that although individ-
uals with BPD were equally likely to recognize the emotion of their in-
teractional partners, they did not use this information in the same
way as control participants when evaluating the trustworthiness of an
offer.
2.1.3. Social problem-solving
Another factor inuencing interpersonal functioning is the ability to
respond exibly to common problems encountered during social interac-
tions. This ability involves functions related to TOM(i.e., the ability to ac-
quire an accurate understanding of social context) as well as problem-
solving skills needed to develop appropriate solutions to interpersonal
difculties. The means-end problem-solving task (MEPS; Platt, Spivak, &
Bloom, 1971) has been used in several studies as an assessment of social
problem-solving in BPD. Participants are asked to determine how they
would arrive at a given solution to an interpersonal problem when they
are provided with the beginning and end of the problem scenario and
responses are then coded on relevant dimensions such as appropriate-
ness, activity, passivity, and focus on emotion regulation. The results of
several studies suggest that BPD is associated with more passive social
problem-solving means (Kehrer & Linehan, 1996; Kremers, Spinhoven,
Van der Does, & Van Dyck, 2006) and individuals with BPD provide
responses on the MEPS that are less relevant to the problem (Maurex
et al., 2010) compared to healthy controls. Further, when compared to
healthy controls and those with other Axis I and Axis II disorders, individ-
uals with BPD and clinical controls provided solutions that were less rel-
evant, effective, and specic than healthy controls (Bray, Barrowclough, &
Lobban, 2007). While impairments in both patient groups may suggest
that the decits are related to negative affect or psychopathology in
general, there is evidence that those with BPD provided responses that
were less specic than both clinical and healthy controls. Further,
in a sample of individuals with BPD who were chronically suicidal,
Kehrer and Linehan (1996) found that inappropriate means on the
MEPS (i.e., substance abuse, lying, parasuicidal behavior) at four and
eight months signicantly predicted subsequent NSSI (i.e., parasuicidal)
behaviors. These studies consistently nd worse performance on the
MEPS for those with BPD than controls. In addition, while those with
other PDs may share some decits in social problem-solving with those
who suffer from BPD, there also appear to be impairments that are
unique to BPD, such as reduced specicity of means. Because difculties
with social problem-solving are related to serious outcomes in BPD,
such as NSSI, further research is needed to clarify whether quality of
social problem-solving is differentially impaired among individuals
with BPD compared to other clinical populations.
Using the observation that many problematic behaviors associated
with BPD occur in the context of emotional arousal, Dixon-Gordon,
Chapman, Lovasz, and Walters (2011) explored the hypothesis that a
negative emotion induction may interfere with the problem-solving
abilities of individuals with BPD features. Their results suggest that
emotional context is an important factor to consider when evaluating
the relation between social problem-solving skills and BPD. Following
a negative emotion induction (i.e., imagining rejection from a romantic
partner and then from friends while seeking support), the high BPD
features group generated fewer relevant solutions and more inappro-
priate solutions to social problems than the low BPD features group.
In addition, increases in self-reported negative emotions in response
to the rejection stressor mediated the relationship between BPDfeatures
and reduced social problem-solving.
Thus, the results from several studies using the MEPS indicate
impaired social problem-solving in BPD. This suggests that decits in
interpersonal functioning are at least partially related to trouble coming
up withspecic, active solutions when faced withdifcult interpersonal
interactions. The study by Dixon-Gordon et al. (2011) highlights the
importance of context, specically emotional state, in the assessment
of interpersonal functioning in those with BPD. As a next step in this
research, it will be important to replicate these effects in a sample of in-
dividuals meeting diagnostic criteria for BPD, as opposed to heightened
BPDfeatures. As suggested when evaluating the facial affect recognition
literature, it is possible that heightened baseline emotional arousal in
BPD interferes with performance on social problem-solving tasks.
2.2. Reactivity to interpersonal stressors
As reviewed above, individuals with BPD may not consistently
demonstrate a perceptual bias, but there is some evidence that they
have stronger emotional reactions in the context of social interactions
compared to others. In research examining reactivity to interpersonal
stressors, vignettes describing interpersonal situations, behavioral
tasks approximating social contexts, and actual interpersonal interac-
tions are used to examine self-reported emotional reactions and biolog-
ical correlates of these stressors. Tragesser et al. (2008) found that
undergraduates with high BPD features reported that they would be
more likely to feel both angry and sad in reaction to imagined teasing
than those with low BPD features, regardless of the source (i.e., friend
or stranger) or the content (i.e., sensitive or non-sensitive topic) of the
teasing. However, in a laboratory paradigm involving negative social
198 S.A. Lazarus et al. / Clinical Psychology Review 34 (2014) 193205
and academic feedback, Chapman, Walters, and Dixon-Gordon (2012)
found that the content of the social feedback did inuence emotional
reactions. In a social feedback condition, but not an academic feedback
condition, individuals with high BPD features showed a signicant
increase in negative emotions. Controls showed the opposite pattern
(i.e., a signicant increase in negative emotions to the academic stress-
or, but not the social stressor). This suggests that individuals with
elevated BPD features may be especially emotionally sensitive to feed-
back when it involves self-relevant social information and may be less
sensitive to feedback related to performance (even when it is equally
self-relevant). While Tragesser et al. (2008) found no effect of the
source of the feedback, the authors suggest that the study may not
have had adequate power to detect these differences in their sample.
Also, in the manipulation by Chapman et al. (2012), participants
believed they were receiving feedback from an actual peer rather than
imagining themselves in the scenario; it is likely that actual feedback
is a more powerful stressor than imagined teasing. Taken together,
these studies lend support to the conclusion that individuals with ele-
vated BPD features may experience more unpleasant emotions
(e.g., anger, sadness) in stressful interpersonal contexts compared
to other contexts and/or individuals with low BPD features.
In a series of studies examining the reactions of individuals withBPD
to an interpersonal stressor, Staebler et al. (2011) and Renneberg et al.
(2011) used Cyberball (Williams & Jarvis, 2006), a virtual ball toss
game, to simulate social inclusionor exclusion. Participants (i.e., females
with BPD and healthy controls) were told they were playing the ball
toss game in order to practice their mental visualization skills with
two other participants and were randomly assigned to either an inclu-
sion or exclusion condition. Participants with BPD reported receiving
the ball a lower percentage of the time in the inclusion condition than
controls (Staebler et al., 2011) and felt more readily excluded regardless
of condition (Renneberg et al., 2011). In terms of subjective emotional
responses, in both studies individuals with BPD reported more negative
emotions than controls overall, regardless of condition (i.e., inclusion
or exclusion). In the Staebler et al. (2011) study, individuals with BPD
reported greater self-focused negative emotions (e.g., sadness,
loneliness) than controls both before and after playing Cyberball.
After exclusion, those with BPD had an increase in other-focused
emotions (e.g., resentment, anger) whereas controls did not. These
results suggest that the interpersonal difculties experienced by individ-
uals withBPDmay be relatedto a biased perceptionof inclusionor partic-
ipation and an increased likelihood to experience negative emotions
across social contexts, compared to controls. Further, it appears that
negative other-focused emotions are particularly impacted by exclusion
for individuals with BPD, while self-focused negative emotions tend to
be higher in those with BPD than controls overall.
Studies that examine the biological underpinnings of emotional
reactivity point to several potential neurobiological correlates of stron-
ger emotional responses to interpersonally relevant contexts and stim-
uli. For example, Walter et al. (2008) examined salivary cortisol levels in
individuals withBPDand controls inresponse to a 10-minute discussion
with their mothers of a conict topic provided by the participants.
Although participants with BPD did not differ from controls on baseline
or peak cortisol levels, they showed a delayed recovery of cortisol re-
sponse following the conict discussions, supporting the theoretical
assertion that individuals with BPD have a slower return to baseline
after emotional arousal (Linehan, 1993). Similarly, using a public speak-
ing social stressor, Simeon, Knutelska, Smith, Baker, and Hollander
(2007) examined hypothalamic-pituitary-adrenal (HPA) axis activity
(through cortisol and norepinephrine levels) as a function of dissocia-
tion, a criterion for BPD. When BPD participants with either high or
low dissociative experiences were compared with healthy controls,
the three groups differed signicantly in peak cortisol reactivity, with
the BPD high dissociation group having a more robust peak response
than the BPD low dissociation and control groups; the BPD low dissoci-
ation group did not differ from controls. There were no differences in
norepinephrine stress reactivity. This suggests that dissociative process-
es in the context of public speaking among individuals with BPD may
lead to or be the result of higher cortisol activity. Future studies are
needed to replicate and extend these nding to other BPD-relevant
interpersonal contexts. The ndings of these two studies combined
point to the possibility that individuals with BPD may have increased
cortisol reactivity (perhaps primarily in the delayed return to baseline)
in stressful interpersonal contexts.
At least one study has used imaging technology to examine differ-
ences in response to interpersonal stimuli between those with and
without BPD(i.e., healthy controls). Ruocco et al. (2010) used functional
near infrared spectroscopy (FNIRS) to assess neural activity during a
task that simulated social inclusion and exclusion via a card game
played with confederates. In analyses focusing on the medial prefrontal
cortex (mPFC), an area implicated in socialcognitive functions related
to the self and interactions with others (Saxe, 2006), BPD and healthy
control participants showed similar levels of oxygenated hemoglobin
in the inclusion condition. When excluded from the card game for
most of the scan, participants with BPD showed greater activation in
the left mPFC than controls. This nding is consistent with previous
research reporting that individuals with BPD have dysfunction in
fronto-lymbic circuitry (New, Goodman, Triebwasser, & Siever, 2008).
However, some studies nd frontal hypoactivation in cognitive control
areas when attempting to regulate emotional reactions to interpersonal
stimuli in BPD (e.g., Koenigsberg et al., 2009). Thus, it appears that PFC
control in response to emotional reactions, which likely plays a role in
top-down regulation of emotion, often differs in those with BPD and
healthy controls. Whether this difference is consistently reected in
increased or diminished reactivity or both increased and diminished
reactivity in divergent contexts, however, remains unanswered.
Further, the extent to which dysfunction in cognitive control areas,
hyperactivity of limbic regions, or issues of connectivity among these
areas play a role in interpersonal disruptions in BPD is still unclear.
As newer technology (e.g., Magnetoencephalography; MEG) allows us
to build in more ne-grained analyses of temporal responding, hopefully
we can better understand this neurological cascade.
These studies examining reactivity to interpersonal stressors in BPD
collectively suggest that individuals with BPD may have different
biological reactions to interpersonal situations, including greater corti-
sol response to social stressors and more neural activation in the left
medial prefrontal areas in response to social exclusion, than control
participants. Also, individuals with BPD have greater self-reported
emotional reactions (i.e., more negative affect and anger) to interper-
sonal stressors compared both to non-interpersonal stressors and
other participants. Individuals with BPD may be more likely to perceive
exclusion and appear to have stronger negative emotions in contexts
that highlight participation, regardless of inclusion or exclusion feed-
back. An important next step in this area of research is to replicate and
extend the ndings reviewed above using samples of individuals meet-
ing full criteria for BPD and clinical control groups alongside healthy
controls. Until such studies are conducted, it will not be clear whether
the ndings above can be considered conclusive and specic to BPD.
2.3. Interpersonal aggression
Another area of impairment that has been investigated in BPD is
interpersonal aggression. Although aggressive behaviors are widely
considered to be central to BPD, few studies have examined aggression
in an interpersonal context experimentally. As expected, BPD is associ-
ated with increased aggression in interpersonal contexts. In response
to vignettes describing teasing scenarios, BPD features were related to
wanting to engage in aggressive behaviors, such as glaring at someone
or making retaliatory comments (Tragesser et al., 2008). BPD features
were also related to ratings of the imagined likelihood of engaging in
the aggressive behavior. Other research in this area utilizes a behavioral
laboratory task that assesses aggressive responding (i.e., Point-
199 S.A. Lazarus et al. / Clinical Psychology Review 34 (2014) 193205
Subtraction Aggression Paradigm; PSAP) in which participants believe
they are playing a game against an opponent and can either accumulate
money for themselves or subtract money from their opponents. On
this task, individuals with BPD consistently respond more aggres-
sively (i.e., subtracting from one's opponent) than healthy controls
(Dougherty, Bjork, Huckabee, Moeller, & Swann, 1999; McCloskey
et al., 2009). In a study by McCloskey et al. (2009), both BPD and
other personality disorder (OPD) groups showed elevated levels of
aggressive responding on the PSAP compared to the control group
and did not differ from each other. However, self-reported aggression
was related to aggressive responding in the BPD group but not in the
OPD group, suggesting aggressive responding on the PSAP for this
group may reect something other than trait aggression. Alternatively,
the OPD group may be less likely to see themselves as aggressive com-
pared to those with BPD, despite displaying similar levels of behavioral
aggression.
Newet al. (2009) examined the neural correlates of aggression using
the PSAP among individuals with BPDwho were high in aggressiveness,
as evidenced by meeting criteria for intermittent explosive disorder
(IED), and healthy controls. Participants with both BPD and IED were
more aggressive than controls on the PSAP and also showed greater
activation in areas of the brain associated with emotion, including
the amygdala and orbitofrontal cortex, whereas healthy controls had
increased activation in brain regions involved in top-down cognitive
control, such as the dorsal prefrontal cortex. Thus, the ndings from
this study support previous research ndings that individuals with
BPD have increased aggressive responding, and add to this literature
by suggesting that there is corresponding activation in regions of the
brain associated with emotional processing and no increase in activa-
tion in emotional control centers during aggressive behavior.
Overall, the studies investigating interpersonal aggression using a
behavioral measure (PSAP) suggest that individuals with BPD may
engage in more aggressive behavior in some experimentally manipulat-
ed interpersonal situations compared to healthy controls. The para-
digms (e.g., being teased, monetary games) used in these studies
suggest that in this context emotion may precede aggression to
some degree but do not rule out the possibility that aggression pre-
cedes emotional response or that both are related to a third variable,
such as impulsivity, in interpersonal interactions. Although this re-
search supports the hypothesis that individuals with BPD tend
to react more aggressively than others in interpersonal contexts,
studies are needed that use clinical controls and occur in naturalistic
settings to help advance an understanding of specic interpersonal
contexts that differentially predict aggression among individuals
with BPD compared to those with other psychiatric disorders.
2.4. Lack of cooperation/trust
Recently, tasks from behavioral economics research involving trust
and cooperation have been used to gain further insight into the inter-
personal functioning of individuals with BPD. These tasks involve
relying on others as well as understanding and responding to interper-
sonal cues. Unoka, Seres, Aspan, Bodi, and Keri (2009) found that indi-
viduals with BPD were less likely to invest money (i.e., trust their
partner) than controls and depressed individuals, although they did
not differ in their risk taking behavior. Further, those with BPD predict-
ed worse outcomes for the trust game than controls and while controls
increased the amount of money invested across trials there was no such
trend for the BPD group. Interpersonal and cognitive symptoms of BPD
accounted for 33% of the variance in the total amount of money invested
in the trust game, leading the authors to suggest that decreased trust
and the resultant behavioral performance in the game may be related
to symptoms such as stress-related paranoia, identity disturbance,
dissociation, and problems in interpersonal relationships.
In addition, individuals with BPD appear to be less skilled at cooper-
ation andbehavior aimed at repairing ruptures than controls. In a multi-
round economic exchange game, King-Casas et al. (2008) observed that
dyads witha BPDtrustee showeda downward shift ininvestment levels
in late rounds of the game, reecting a break in cooperation. Healthy
trustees were twice as likely as BPD trustees to coax (show generous
gestures) in the presence of lowoffers, reecting an attempt to enhance
cooperation. During participation, when compared to controls, individ-
uals withBPDexhibiteddifferential responding inthe anterior insula, an
area known to respond to normviolations in various paradigms. Neuro-
imaging results indicated that whereas healthy controls showed strong
linear responses in anterior insula activity to both offers from partners
and money they repaid, BPD patients' insula activity was only related
to the amount of money offered, not the amount repaid. Whereas the
behavioral ndings suggest that individuals with BPD are not attempting
to repair breaks in cooperation, the neuroimaging ndings indicate that
these results require a more precise characterization. Specically, the
impairment for individuals with BPD may not be the ability to repair
ruptures in cooperation, but a failure to perceive lowoffers frompartners
as violations of social norms, and, hence, a failure to see the need to repair
the interpersonal transgression. This study highlights the importance
of using biological measures in addition to behavioral assessments.
When individuals with BPD demonstrate behavioral decits compared
to controls, there may be biological correlates of the behavioral decits
that point to potential mechanisms. Alternatively, when decits are
evident according to biological but not behavioral measures, we may
suspect that individuals with BPD and controls are arriving at similar
observable performances by divergent processes.
One potential biological correlate of these apparent decits in trust
and cooperation may be oxytocin, a neuropeptide posited to play a
central role in prosocial behavior (Carter, Williams, Witt, & Insel, 1992)
and perceived trustworthiness of faces in humans (Theodoridou, Rowe,
Penton-Voak, & Rogers, 2009). However, given that Oxytocin is also
thought to increase the salience of social cues, Bartz et al. (2010)
hypothesized that it might heighten concerns of rejection and abandon-
ment in individuals with BPD, negatively impacting trust and coopera-
tion. In this study, participants with BPD and healthy controls received
intranasal oxytocin or placebo and played the assurance game (devel-
oped by Kollock (1998)), in which participants choose to cooperate or
defect at the same time as their partner throughout three consecutive
rounds. For BPD participants, oxytocin did not have its usual trust-
facilitating effects. Compared to those receiving placebo, BPD partici-
pants receiving Oxytocin predicted less cooperation from partners and
were more likely to defect in response to hypothetical partner coopera-
tion, whereas controls followed the expected (i.e., opposite) pattern
(expectation of more cooperation and increased likelihood of coopera-
tion in response to hypothetical partner cooperation when receiving
oxytocin compared to placebo). These ndings support the authors'
hypothesis that preexisting relationship expectancies may moderate
the inuence of oxytocin on prosocial behavior.
In sum, it appears that individuals with BPD may be less likely than
controls to cooperate in experimentally manipulated interpersonal
contexts. Specically, breakdowns in cooperation appear to be related
to reduced trust in interactional partners as opposed to impulsivity in
interpersonal situations (Unoka et al., 2009) or external reward associ-
ated with cooperation (Bartz et al., 2010). Further, there is preliminary
evidence that oxytocin, known to enhance prosocial behavior, may
have paradoxical effects on individuals with BPD. It is important to
follow up this line of research to determine how personality constructs
(e.g., attachment, avoidance), biological variables (e.g., oxytocin levels,
amygdala activity), and interpersonal behaviors (e.g., cooperation,
trust) interact to predict changes in trust and cooperation for those
with BPD.
2.5. Behavior within motherchild interactions
Researchers recently have begun to use behavioral measures of
motherinfant interactions within a laboratory setting to investigate
200 S.A. Lazarus et al. / Clinical Psychology Review 34 (2014) 193205
interpersonal functioning in BPD. Several studies have examined how
mothers with BPD differ from typical mothers by coding maternal
behavior ininteractions with their infants. These laboratory interactions
include periods of face-to-face play and also situations that may be
stressful to the infant, such as periods when the mother adopts a
still-face. Overall, mothers with BPD tend to behave more intrusively
(i.e., behavior that overwhelms or interferes with the child's efforts)
and less sensitively (i.e., behavior that is not responsive to the child's
needs), and are less competent at structuring their children's activities
than control mothers (Crandell, Patrick, & Hobson, 2003; Hobson,
Patrick, Crandell, Garca-Prez, & Lee, 2005; Newman, Stevenson,
Bergman, & Boyce, 2007).
One laboratory procedure that has beenused extensively to examine
the behavior of mothers and their infants, the strange situation proce-
dure (Ainsworth, Blehar, Waters, & Wall, 1978), has also been utilized
with mothers with BPD to assess behavior during separationreunion
episodes. Using this methodology, Hobson et al. (2009) found that a
higher proportion of mothers with BPD(85%) was classied as showing
disrupted communication (e.g., mixed affective signals, inadequate
responding to the infant's needs) than mothers with MDD (47%) and
control (42%) mothers. Mothers with BPD also showed higher rates
of frightened/disoriented behavior compared to mothers with MDD or
healthy control mothers.
In addition to the increased rates of problematic interactions with
their children, mothers with high BPD pathology also are less likely
than those with lowBPDpathology to display positive affect in response
to infant distress (Kiel, Gratz, Moore, Latzman, & Tull, 2011) and engage
in fewer afliative behaviors than control mothers (e.g., smiling and
imitating) during typical interactions (White, Flanagan, Martin,
& Silvermann, 2011). Specically, White et al. (2011) observed the
interactions of mothers with BPD, MDD, BPD + MDD, and healthy
controls with their infants (mean age = 3.5 months). During the inter-
actions, the mothers were told to interact with their infant as they
would at home. Control mothers smiled more than mothers with
MDD, BPD, and BPD +MDD whereas mothers with MDD smiled signif-
icantly more than mothers with BPD and BPD + MDD. In addition,
mothers with MDD touched their infants more than mothers with BPD
and BPD + MDD. In terms of game playing, both control and MDD
mothers engaged in more game playing than BPD and BPD + MDD
mothers, but they did not differ from each other. Lastly, mothers with
BPD displayed less imitation with their infants than control mothers,
mothers with MDD, or mothers with BPD + MDD. Although mothers
with MDD were less responsive than controls in some behaviors, such
as smiling, mothers with BPD (with or without MDD) showed the
most consistent impairments.
Kiel et al. (2011) examined the transactional nature of motherchild
interactions; they reported that insensitive parenting by those with
signicant BPD pathology increased as infant distress persisted. For
all dyads, infant distress was sensitive to maternal responsiveness,
decreasing after positive affect and increasing after insensitivity by
mothers. This mutual inuence within the dyad underscores the impor-
tance of considering the transactional nature of motherinfant interac-
tions, and interpersonal interactions more generally. Taken together,
these studies suggest that mothers with BPD tend to be less competent
in interacting with their infants, displaying decits in areas such as
sensitivity, structuring, and coping with infant distress.
3. Discussion
The research reviewed here suggests several key areas of interper-
sonal impairment among individuals with BPD. First, consistent with
object relations and cognitive theories of the disorder, individuals
with BPD tend to view others more negatively and have more negative
expectations for relationships than healthy controls. However, given
that Tragesser et al. (2008) failed to nd that BPD features were related
to more negative views of an imagined teaser, it is unclear in which
contexts a negative bias towards others may be most likely to occur.
Additional research is needed to characterize negative interpersonal
interpretations and conclusions made by those with BPD using contex-
tual and BPD-relevant cues, including emotionally evocative contexts.
Together, research conducted in both laboratory and naturalistic
settings will be needed to delineate the specic problematic ways in
whichindividuals with BPDrespondto others in interpersonal contexts.
There are an increasing number of studies, with diverse methodolo-
gies ranging from behavioral economics paradigms to neuroimaging
technology, that examine the ability of individuals with BPD to under-
stand and interpret the mental states of others. The ndings from these
studies are somewhat mixed. In a number of studies, individuals with
BPD do not differ from healthy controls in TOM skills and are able to
appropriately understand and respond to social cues. However, there
is some evidence to support the contention made by object relations
theorists that those with BPDare less skilled at inferring the mental states
of others and may struggle to apply and utilize these abilities across
contexts. Harari et al. (2010) suggest one possibility for synthesizing
these ndings; namely that affective empathy is intact and cognitive
empathy/understanding is impaired. In other words, individuals with
BPD may be accurately sensing and connecting to the emotions others
are feeling while simultaneously having difculty understanding or
cognitively contextualizing the emotions and thoughts of others. This is
supported by the neuroimaging ndings from Mier et al. (2012), which
suggest that whereas amygdala hyperactivation may reect exaggerated
or increased sensitivity to affective perception of others' emotions, inade-
quate regulation through frontal regions may lead to impaired cognitive
understanding in complex or emotional contexts. Further, this combina-
tion of hyperactive emotional responding (i.e., experience of emotion)
combined with hypoactive emotion regulation (i.e., changing the course
of emotion) may result in what appears to be erratic and/or impulsive
behavior.
Our understanding of this complex relationship would be furthered
by research examining cognitive and emotional processing, as mecha-
nisms of interpersonal behavior, across various levels of analysis (e.g.,
brain, behavior). The recent advent of the National Institute for Mental
Health's (NIMH) Research Domain Criteria (RDoC; http://www.nimh.
nih.gov/research-priorities/rdoc/index.shtml) may prove useful for
future research in this area. For example, the RDoC may help provide
direction to researchers seeking to better understand the underlying
processes contributing to interpersonal impairments relevant, but
perhaps non-specic, to BPD. Including multiple levels of analysis
should help to contribute to the most ne-grained characterization.
Finally, systematically manipulating contextual variables that may
serve as moderators of a BPDTOM relationship (e.g., relationship/
history with the interpersonal partner, emotional load, contextual
cues) may help clarify the extent and pervasiveness of TOM decits.
One replicated result in the literature is that individuals with BPD
tend to demonstrate impairment in social problem-solving skills com-
pared to others. Multiple ndings indicate that when attempting to
solve interpersonally-relevant problems, individuals with BPD have a
tendency to produce less effective means and more passive solutions.
In addition, there is some evidence consistent with the biosocial theory
that social problem-solving abilities are more adversely impacted by
negative affect for individuals with BPD features than others. In the
future, the role of emotion may be explicated by examining social
problem-solving in more externally valid contexts, such as actual inter-
personal conicts in the laboratory. This is important given that in
behavioral tasks that approximate interpersonal situations, individuals
with BPD report stronger subjective emotional reactions to stressful
social situations than other individuals (Tragesser et al., 2008), and
respond more strongly to social stressors than other types of stressors
(Chapman et al., 2012).
Overall, the research on social cognition is complex, but has the
potential to provide valuable insight into the interpersonal difculties
of those with BPD. It is important to understand and incorporate
201 S.A. Lazarus et al. / Clinical Psychology Review 34 (2014) 193205
potential decits in social cognition when evaluating ndings from
other domains. For example, the ability to accurately perceive facial
emotion and understand the intentions and thoughts of others is an im-
portant part of evaluating the trustworthiness of a potential partner.
More careful attention should be paid to alternative explanations,
such as differences in social cognition and affect recognition, when
interpreting differences between individuals with BPD and others in in-
terpersonal behavioral tasks (such as cooperation tasks). Because indi-
viduals with BPD may experience decits in several areas of
interpersonal functioning, increasing the number of interpersonal do-
mains assessed within a given study will allow for direct comparisons
of areas of difculty.
Across the studies reviewed here, there is evidence of biological dif-
ferences between individuals with BPD and others when processing
interpersonal stimuli. First, increased emotional reactivity to interper-
sonal stimuli and contexts may be reected in increased activation in
the amygdala (Mier et al., 2012; New et al., 2009), increased cortisol
reactivity (slower return to baseline than controls; Walter et al.,
2008), and heightened activation in the mPFC (Ruocco et al., 2010).
Second, there may be decreased activation in areas related to the ability
to think about others (i.e., left superior sulcus and gyrus) and increased
activation in areas related to self-oriented emotional reactions to others
(i.e., right middle insular cortex; Dziobek et al., 2011). The increase in
activation in the right middle insular cortex may reect something
akin to affective empathy; however, it is possible that the increased
activation also leads to over-arousal in individuals with BPD. Neuroim-
aging ndings by Mier et al. (2012) provide some support for the over-
arousal hypothesis. The authors found that while controls showed
activation in the mirror neuron system during a TOM task, those with
BPDactually showed hypoactivation. This may reect implicit biological
strategies to regulate strong emotional reactions. Further, the neural
hypoactivation was not accompanied by any behavioral evidence of
TOM decits in those with BPD. Biological assessments of interpersonal
functioning allowfor identication of mechanisms related to behavioral
differences between those with BPD and others and also provide infor-
mation about different biological pathways that may lead to the same
behavioral outcomes. Thus, while biological methods may provide
means to test hypotheses about the mechanisms that underlie certain
behavioral differences between those with BPD and controls, they
may also suggest that different processes are at work for those with
BPD and controls even when there are no differences in behavioral
ndings.
As suggested by Daros et al. (2013) and consistent with the biosocial
theory, baseline emotional arousal may explain some of the discrepant
ndings in studies of interpersonal functioning for those with BPD.
Although the authors discuss their hypothesis within the domain of
facial affect recognition, it may be applicable to understanding inconsis-
tent ndings in other areas as well. As suggested above, the discrepant
ndings in behavioral tasks assessing TOM may be related to varying
levels of BPD symptoms interacting with the valence and arousal level
of the stimuli. However, these factors are rarely accounted for in studies
of interpersonal behavior. Further, although it may be assumed that
stimuli of negative valence will be more emotionally arousing for indi-
viduals with BPD, this is still unclear. Thus, in any methodology that
employs social stimuli, it will be important to be aware of and account
for the valence and arousal level of those stimuli. Further, given that
individuals with BPD are known to experience affective instability and
intense emotions (for review see Rosenthal et al. (2008)), it is likely
important to include state measures of emotion in studies with inter-
personal stressors to explicate long-standing abilities from temporary
decits due to emotional over-arousal. Although we may assume that
BPD symptoms are generally related to higher emotional arousal, this
may not be true for all individuals with BPD. Other symptoms of the
disorder such as dissociation or biological processes aimed at down-
regulation of sympathetic activity may be related to lower baseline
arousal in some individuals at some times. Without such considerations,
the role of emotional experiences and emotion regulation difculties
in problems of trust, cooperation, aggression, or other interpersonal
behaviors may be overlooked.
Although there are several domains of mixed ndings within inter-
personal functioning in those with BPD, a consensus appears to be
developing that disrupted interpersonal functioning in BPD extends to
maternal behavior. Across a range of interactions, including free play,
separation and reunion, and following still-face periods, mothers with
BPD behave less responsively towards their infants than mothers with-
out BPDpathology. Inaddition, this research(e.g., Kiel et al., 2011) high-
lights the transactional nature of interactions between mothers and
infants, showing that infant distress leads to more insensitive parenting,
which then leads to more infant distress. It is of note that the problem-
atic transactions between mothers with BPDand their children are con-
sistent with hypotheses generated from each of the primary theories of
BPD development. Laboratory-based interpersonal interaction between
mother and infant may be a useful model for researchexamining similar
types of interpersonal behavior with adult partners. Additionally,
longitudinal research that follows the children of mothers with
BPD may provide important information about the development of
interpersonal and emotion regulation skills given different develop-
mental experiences in these areas.
The ndings reviewed here can be integrated to create several
testable models of interpersonal dysfunction in those with BPD. One
such model, consistent with both object relations and biosocial theories,
would suggest that early insensitive, intrusive, or erratic interactions
(perhaps with mothers with BPD or BPD features) lead to an increased
vulnerability to interpersonal dysfunction in BPD. Although these
ndings do not necessarily suggest that all individuals with BPD have
parents with the disorder, some studies suggest that the interpersonal
symptoms of BPD are heritable (Zanarini et al., 2004). The vulnerability
to interpersonal dysfunction may be characterized by mistrust of others,
hypervigilance to rejection or abandonment cues, and difculty recog-
nizing and understanding emotions and extralinguistic cues from
others. These vulnerabilities may increase the likelihood that those
with BPD will perceive threat or nd themselves in more problematic
interpersonal situations. When threat is perceived (whether accurate
or not), emotional (e.g., anger, rejection), behavioral (e.g., aggression),
and biological (e.g., slow return to baseline after cortisol reactivity,
increased amygdala activation, diminished PFC control) changes occur
which make self-regulation difcult. In addition, those with BPD are
likely to be less able to generate active and effective solutions in inter-
personal situations which, in the face of dysregulated emotions, may
lead to ineffective behaviors such as impulsivity and aggression, which
in turn may further increase interpersonal stressors. Finally, in a chronic
state of heightened affect, the individual is likely to perceive additional
social threats, thus creating a vicious cycle. These different domains of
functioning have not been tested concurrently and the vast majority
of the studies reviewed here do not include longitudinal data. As such,
it is premature to drawconclusions about the temporal and transactional
relations that characterize interpersonal dysfunction for those with BPD
but hypotheses such as these offer directions for future research.
3.1. Future directions
Given that interpersonal dysfunction is part of the diagnostic criteria
of BPD, it is important for researchon this topic to move beyond demon-
strating that individuals with BPD report having more difculties in
interpersonal functioning than healthy controls. To optimally character-
ize interpersonal dysfunction in BPD, it may be useful for future studies to
avoid tautological outcomes by using dependent measures of interper-
sonal functioning that do not directly overlap with any given diagnostic
criterionfor BPDor by removing relevant criteria whenexamining the re-
lationbetweenBPDand interpersonal outcomes. For example, the DSM-5
(APA, 2013) lists frantic efforts to avoid abandonment, patterns of unsta-
ble relationships, interpersonal impulsivity, and aggression as diagnostic
202 S.A. Lazarus et al. / Clinical Psychology Review 34 (2014) 193205
criteria for BPD. As such, measures of interpersonal difculty that are not
confounded with these criteria will reduce problematic overlap between
predictor and outcome variables. Alternatively, studies aiming to charac-
terize interpersonal dysfunction in BPD could examine the contexts (e.g.,
emotional arousal, interpersonal rejection) under whichspecic interper-
sonal impairments are more or less likely to be elicited. Such anapproach
would help to more precisely characterize interpersonal dysfunction in
BPD beyond acontextual diagnostic constructs (e.g., reactive aggres-
sion), and may help to rene theoretical models and inform novel ap-
proaches to treatment. Finally, as we emphasize here, using multiple
modes of assessment may avoid this potential confound between BPD
diagnosis and interpersonal functioning. Specically, rather than using
self-reported BPD symptoms to predict self-reported interpersonal
functioning, multimodal assessments provide a more detailed under-
standing of behavioral and physiological correlates of interpersonal
problems in BPD.
Further, including multi-modal assessments of interpersonal
constructs will increase condence that the characterizations of inter-
personal problems for those with BPD are valid and stable. The NIMH
RDoC may provide a useful heuristic framework to inuence research
in this area. Areas such as trust and cooperation are good examples of
domains that have discrete, observable social behaviors that lend
themselves to examinations involving both behavioral and biological
assessments. The literature to date, including behavioral, biological, and
self-report data, suggests that trust andcooperationare impairedfor indi-
viduals with BPD. Given this consistency, we suggest that it is nowappro-
priate to extend these studies to more ecologically valid contexts. For
example, the role of trust and cooperation may be examined in therapy
relationships or in relationships with meaningful others at varying levels
of closeness. Further, it will be important to use informant methods to
assess interpersonal symptoms in BPD, as the impact of these problems
on others may be an important part of the picture. In addition, the next
generation of treatments for BPD may benet from including interven-
tions specically targeting skills neededto enhance trust andcooperation.
Another area that deserves attention is related to determining the
degree to which particular interpersonal impairments are specic to
BPD. BPD has particularly high rates of comorbidity (or covariance)
with many other disorders (e.g., MDD, post-traumatic stress disorder,
substance use disorders, avoidant PD, narcissistic PD). As such, it is
difcult to parse apart interpersonal dysfunction that is specic to BPD
from interpersonal dysfunction associated with difcult personality
traits more broadly (e.g., Neuroticism, impulsivity) or with severity of
psychopathology (which may be reected, in part, by meeting criteria
for several disorders simultaneously). Some authors of the papers
reviewed here have made attempts to begin addressing these issues
by including relevant clinical control groups (e.g., MDD, Cluster C
PDs, BPD + MDD) or including measures of relevant personality traits
(e.g., impulsivity) or problematic behaviors (e.g., NSSI). We have tried
to highlight ndings that are specic to individuals with BPDas opposed
to ndings that differentiate all clinical groups from healthy controls.
Future researchers should include control groups that cover the span
of diagnostic overlap with BPD from the most similar (e.g., narcissistic
PD, antisocial PD) to more dissimilar (e.g., avoidant PD, MDD).
Finally, characterizing interpersonal difculties associated with BPD
is complicated by the heterogeneity of BPD presentations. BPD is,
by current denitions, an extremely heterogeneous disorder and two
individuals could both meet diagnostic criteria for BPD while sharing
only one diagnostic criterion. Additionally, unlike some disorders
(e.g., MDD), there are no necessary criteria for meeting the diagnostic
threshold in BPD. As such, some of the mixed interpersonal ndings
reviewed here may result from individuals with BPD who have quite
dissimilar vulnerabilities and reactions to interpersonal stressors. In
the future, researchers may want to include samples that meet criteria
for BPD and also share a common symptom cluster. For example,
New et al. (2009) recruited participants who met criteria for both BPD
and IED to assess aggressive responding. The selection of samples that
increase overlap of symptoms of interest may result in more stable
and informative indicators of interpersonal difculties. Further, the
inclusion of potential moderators in studies of interpersonal function-
ing in BPD would likely aid characterization efforts by capitalizing on
heterogeneity.
In sum, interpersonal behaviors and relationships have long
been theorized as central to the experience and expression of
BPD. A large body of research speaks to the interpersonal distress
and resultant consequences for individuals with BPD. More recently,
researchers have turned their attention to the observable interpersonal
behaviors that differentiate individuals with BPD from others in an
attempt to understand how particular behaviors are related to inter-
personal distress and to identify areas to target when working with
patients with BPD. Based on the review of this literature, there appear
to be replicable differences in the interpersonal behaviors of individuals
with BPD or BPD features and those without such features, particularly
in the areas of trust and cooperation and parenting behaviors. Future
research that increases the ecological validity of assessments will
further add to this knowledge base.
Appendix A. Supplementary data
Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.cpr.2014.01.007.
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