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Hightened sensitivity to facial expressions of


emotion in borderline personality disorder

Article in Emotion December 2006


DOI: 10.1037/1528-3542.6.4.647 Source: PubMed

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Emotion Copyright 2006 by the American Psychological Association
2006, Vol. 6, No. 4, 647 655 1528-3542/06/$12.00 DOI: 10.1037/1528-3542.6.4.647

Heightened Sensitivity to Facial Expressions of Emotion in Borderline


Personality Disorder

Thomas R. Lynch M. Zachary Rosenthal


Duke University and Duke University Medical Center Duke University Medical Center

David S. Kosson Jennifer S. Cheavens


Rosalind Franklin University of Medicine and Science Duke University Medical Center

C. W. Lejuez R. J. R. Blair
University of Maryland National Institute of Mental Health

Individuals with borderline personality disorder (BPD) have been hypothesized to exhibit significant
problems associated with emotional sensitivity. The current study examined emotional sensitivity (i.e.,
low threshold for recognition of emotional stimuli) in BPD by comparing 20 individuals with BPD and
20 normal controls on their accuracy in identifying emotional expressions. Results demonstrated that, as
facial expressions morphed from neutral to maximum intensity, participants with BPD correctly identi-
fied facial affect at an earlier stage than did healthy controls. Participants with BPD were more sensitive
than healthy controls in identifying emotional expressions in general, regardless of valence. These
findings could not be explained by participants with BPD responding faster with more errors. Overall,
results appear to support the contention that heightened emotional sensitivity may be a core feature of
BPD.

Keywords: borderline personality disorder, facial affect recognition, emotional sensitivity, facial expres-
sions

Borderline personality disorder (BPD) is a serious psychiatric emotional dysregulation is related to a biological disposition for
disorder that is characterized by high utilization of psychiatric greater emotional vulnerability. This vulnerability in BPD is hy-
services and high rates of suicide (Skodol et al., 2002; Surber et al., pothesized to consist of greater emotional sensitivity (low thresh-
1987; Swigar, Astrachan, Levine, Mayfield, & Radovich, 1991; old for recognition of emotional stimuli), greater emotional reac-
Widiger & Frances, 1989; Widiger & Weissman, 1991). Despite a tivity (high amplitude of emotional responses), and a slower return
dearth of research examining the core components of BPD, there to baseline arousal (long duration of emotional responses; Linehan,
is growing consensus that individuals with BPD exhibit significant 1993). According to this perspective, clinical features associated
problems associated with affective instability (Linehan, 1993; with BPD (e.g., interpersonal difficulties, impulsivity, suicidality)
Skodol et al., 2002; Westen, 1991), with some arguing that affec- are a consequence of problems associated with emotional vulner-
tive instability or problems with emotion regulation is the core ability and difficulties regulating emotion (Linehan, 1993; Lynch,
feature of the disorder (Linehan, 1993; Siever, Koenigsberg, & Chapman, Rosenthal, Kuo, & Linehan, in press). The purpose of
Reynolds, 2003; Westen, 1991). Linehan (1993) has theorized that the current study was to examine the emotional sensitivity com-
ponent of emotional vulnerability using a facial affect recognition
task designed to measure sensitivity to low levels of emotional
Thomas R. Lynch, Department of Psychology: Social and Health Sci-
stimulation.
ences, Duke University, and Department of Psychiatry and Behavioral Facial expressions are nonverbal communicative cues that con-
Sciences, Duke University Medical Center; M. Zachary Rosenthal and vey messages about emotional feelings, behavioral intentions, and
Jennifer S. Cheavens, Department of Psychiatry and Behavioral Sciences, action requests. Across cultures, facial expressions have been
Duke University Medical Center; David S. Kosson, Psychology Depart- shown to signal subjective emotional experience (e.g., Ekman et
ment, Rosalind Franklin University of Medicine and Science; C. W. al., 1987; Horstmann, 2003). In addition, facial expressions have
Lejuez, Department of Psychology, University of Maryland; R. J. R. Blair, been demonstrated to be effective instrumentally: Sad expressions
Mood and Anxiety Program, National Institute of Mental Health.
have been linked with the elicitation of nurturance and inhibition
Manuscript preparation was partially supported by National Institute of
of aggression on the part of the observer of the expression (e.g.
Mental Health Grant MH01614 to Thomas R. Lynch.
Correspondence concerning this article should be addressed to Thomas Eisenberg et al., 1989; Miller & Eisenberg, 1988), and angry
R. Lynch, Department of Psychiatry and Behavioral Sciences, Duke Uni- expressions have been shown to curtail egregious behavior of
versity Medical Center, 2213 Elba Street, Box 3026 Durham, NC 27710. others associated with breaking social rules or expectations (e.g.
E-mail: lynch011@mc.duke.edu Averill, 1982). There is also substantial evidence of stable indi-
647
648 LYNCH ET AL.

vidual differences in the ability to recognize facial expressions, expressions to maximum-intensity (i.e., prototypic) expressions of
with females better than males in adulthood (Hall, 1978) and in emotion. Consequently, it is possible to evaluate not only partic-
childhood (McClure, 2000). ipants accuracy when expression is complete (as in prior studies)
Overall, there is a relative dearth of research examining facial but also how intense a facial expression has to be before accurate
affect perception in BPD. Donegan and colleagues (2003) exam- recognition occurs (i.e., the threshold at which recognition occurs).
ined amygdala reactivity in 15 BPD patients compared with 15 The perspective that individuals with BPD are characterized by
normal controls while viewing facial expression images (neutral, an underlying emotional sensitivity predicts that, compared with
happy, sad, and fearful). BPD patients showed greater left amyg- healthy controls, these individuals should demonstrate correct rec-
dala activation to facial neutral, sad, fearful, and happy facial ognition of emotional stimuli at lower threshold levels regardless
expressions compared with controls. These authors also reported of valence of emotional expression, as measured by accurate
that, in postscan debriefings, some BPD patients interpreted neu- identification of emotional expressions at earlier stages of expres-
tral expressions as negative or threatening. With regard to accuracy sion or intensity. In contrast, the perspective that individuals with
of facial affect identification, Wagner and Linehan (1999) reported BPD are generally impaired at processing affective information or
that women with BPD more accurately labeled fearful facial ex- are specifically impaired at processing fear predicts either accurate
pressions compared with non-BPD control groups with and with- recognition of affective facial expressions only when the intensity
out a history of childhood sexual abuse, although the women with of expression is greater than that required for healthy controls or
BPD were less accurate than nonabused controls at labeling neutral poorer accuracy even with complete expression of emotion.
facial expressions. In contrast, Levine, Marziali, and Hood (1997)
reported that 30 male and female BPD patients were less accurate Method
compared with 40 gender-balanced non-BPD controls at recogniz-
ing facial expressions of anger, fear, and disgust. Participants
In sum, (a) results from one study are consistent with greater Participants were 40 individuals recruited via newspaper advertisements,
emotional responsiveness in BPD (Donegan et al., 2003) and (b) Internet postings, and flyers posted in Duke University Medical Center and
one study suggests that individuals with BPD are more emotion- community locations. Advertisements for the BPD group requested partic-
ally sensitive (Wagner & Linehan, 1999), whereas one study ipation from individuals with depression, BPD, and/or self-injurious be-
suggests that they are less sensitive (Levine et al., 1997). Interest- haviors. Advertisements for the control group targeted individuals inter-
ingly, two of the studies described above suggested that BPD ested in a study of emotions. The mean age of participants was 35.08
individuals have a tendency to inaccurately label fear or to ap- years (SD 11.04). The majority of participants were female (85.0%, n
praise negative intent in neutral facial expressions more often than 34). In addition, most participants were Caucasian (77.5%, n 31), with
the remainder self-identifying as African American (20.0%, n 8), or
did non-BPD control groups, suggesting the possibility of a biased
undisclosed ethnicity (2.5%, n 1). Education level included 5.0% (n
appraisal of or toward fearful stimuli in people with BPD
2) with less than a high school education, 10.0% (n 4) with a high school
(Donegan et al., 2003; Wagner & Linehan, 1999). Even so, prior degree or GED, 32.5% (n 13) with some college experience, 32.5% (n
studies are limited in several ways. First, not all prior studies 13) with a college degree, 17.5% (n 7) with an advanced degree (e.g.,
matched participants on important demographic variables that may masters degree), and 2.5% (n1) did not report educational history. As
have an impact on affect recognition. For example, in the study by shown in Table 1, there were no significant differences on these demo-
Wagner and Linehan (1999), the BPD group was younger than the graphic variables across groups.
two comparison groups, and it appears that age was related to Prospective participants called a study coordinator and received a brief
affect recognition accuracy. Second and most important for the overview of the study over the telephone. If interested, these individuals
current study, all prior studies used facial stimuli at 100% expres- provided verbal informed consent and completed an initial telephone
sion without examining stimuli at lower levels of intensity
(Donegan et al., 2003; Levine et al., 1997; Wagner & Linehan,
1999); consequently, the group differences in accuracy do not Table 1
necessarily reflect differences in sensitivity. In addition, no studies Demographic Information
to date have examined emotional sensitivity (i.e., low threshold for Variable BPD (n 20) Control (n 20)
recognition of emotional stimuli) using dynamic stimuli that pro-
vide a measure of the speed of response combined with response Age
accuracy, although there is evidence that dynamic emotional stim- M 35.5 34.7
SD 11.2 11.2
uli are more effective than static stimuli at activating brain areas Gender
that process emotion (LaBar, Crupain, Voyvodic, & McCarthy, % female 85.0 85.0
2003; Sato, Kochiyama, Yoshikawa, Naito, & Matsumara, 2004). Ethnicity
The current study was designed to provide a more direct test of % Caucasian 89.5 70.0
Linehans (1993) hypothesis regarding emotional sensitivity while % African American 10.5 30.0
Highest grade completed
addressing the limitations of prior studies. First, to assess the % grade school 5.3 5.0
emotional sensitivity of individuals with BPD, and to examine the % high school 10.5 10.0
processing of dynamically changing emotion, we used a paradigm % some college 31.6 35.0
that allowed us to examine participants ability to respond accu- % college degree 31.6 35.0
% advanced degree 21.1 15.0
rately to morphing facial emotional expressions at varying degrees
of intensity. In this paradigm (Blair, Colledge, Murray, & Mitchell, Note. One participant in the borderline personality disorder (BPD) group
2001), faces change gradually and monotonically from neutral did not report demographic data.
FACIAL EXPRESSION IN BPD 649

Figure 1. Example of anger stimulus presentation from the Multimorph Facial Affect Recognition Task.
Stimuli taken from Pictures of Facial Affect (Ekman & Friesen, 1976).

screening with selected Structured Clinical Interview for DSMIV Axis I SCID-II interviews were conducted by M. Zachary Rosenthal, a
Disorders (SCID-I) modules (First, Spitzer, Gibbon, & Williams, 1995); doctoral-level clinical psychologist with expertise in assessment and treat-
using this information, individuals were excluded on the basis of current ment of BPD, and by two clinical assessors trained to reliability and
mania or a history of psychosis. In addition, participants reported current supervised by Thomas R. Lynch. Using videotaped recordings, approxi-
medication use. Finally, participants were scheduled for a diagnostic intake mately 15% of the SCID-II interviews (n 6) were randomly reassessed
and experiment. by a different rater (either M. Zachary Rosenthal or a clinical assessor) in
At the diagnostic intake, participants were screened for personality order to rigorously verify the reliability of the personality disorder group-
disorders using a structured clinical interview (First, Spitzer, Gibbon, ings. Interrater reliability on personality disorder diagnosis was evaluated
Williams, & Benjamin, 1996). Given the high co-occurrence of BPD and using kappa. The resulting kappas ranged from 0.60 ( p .06) to 1.0 ( p
major depressive disorder (Bunce & Coccaro, 1999; Zanarini et al., 1998), .05) across disorders (BPD .71, p .05), reflecting moderate to
we chose to include individuals with comorbid BPD and depressive symp- excellent interrater reliability (Landis & Koch, 1977).
tomatology in the BPD group with the intention of maximizing external HAM-D (Hamilton, 1960). The HAM-D is a 21-item interview mea-
validity.1 Healthy controls were required to evidence (a) minimal symp- suring severity of depressive symptoms. The HAM-D is one of the most
toms of major depression, as defined by Hamilton Depression Rating Scale widely used instruments for measuring depression and has demonstrated
(HAM-D) scores of 6 or less (nondepressed/remission; Frank et al., 1991); high validity and reliability. Scores on the HAM-D represent both the
(b) no diagnosis of a personality disorder; and (c) no evidence of BPD intensity and the frequency of specific symptoms. Interviews were admin-
symptomatology, as defined by no BPD diagnostic criteria above thresh- istered by trained research assistants under the supervision of Thomas R.
old. The mean HAM-D score for the BPD group was 15.85 (SD 6.46), Lynch and M. Zachary Rosenthal.
and the mean score for the control group was 2.80 (SD 2.17, p .001). The Multimorph Facial Affect Recognition Task (Blair et al., 2001) was
Most participants with BPD reported current psychotropic medication developed by using the morphing technique for face stimuli pioneered by
use (n 13), including selective serotonin reuptake inhibitors (SSRIs; n Perrett, May, and Yoshikawa (1994). On each trial of this task, participants
6), antipsychotics (n 1), mood stabilizers (n 2), and multiple medi- observed as a face morphed from a neutral facial expression to one of
cation classes (n 4). In contrast, psychotropic medication use among sadness, happiness, surprise, anger, fear, or disgust (see Figure 1). The
controls was minimal (n 2), and included 1 participant on an SSRI and neutral and affective facial stimuli were taken from the empirically vali-
another on a combination of an SSRI, lithium, and a stimulant. Further- dated Pictures of Facial Affect (Ekman & Friesen, 1976). In the current
more, we excluded individuals who were unable to give consent or were version of this paradigm, the shift from 0% expression to 100% expression
illiterate, as the completion of the task required participants to be able to was divided into 39 stages. Thirty-six trials were presented (6 for each of
read. Comparison group participants were matched to BPD participants on six emotions: anger, fear, sadness, surprise, happiness, and disgust). Each
age and gender. A total of 63 individuals who passed phone screening for trial began with a neutral face, which gradually morphed into a prototypic
the BPD condition completed the diagnostic intake; 20 of them met emotion expression over 39 stages. Participants saw each stage for 450 ms.
diagnostic criteria and were included in this study. On the basis of these Participants were instructed to classify the emotion as soon as they were
inclusion exclusion criteria, the final sample included 20 BPD individuals able to do so by clicking the mouse on a box with the emotion name.
and 20 normal controls. Instructions were as follows:

You will be presented with a series of faces. These faces are initially
Measures
neutral, that is, they have a blank expression. However, the faces will
Demographic information. A short self-report questionnaire was ad- slowly change over many stages, to reveal one of the six target
ministered to obtain age, gender, race, education level, marital status, and emotions listed on the screen. For each face, you will have to deter-
total household income. mine which expression is displayed as soon as possible in as few
Structured Clinical Interview for DSMIV Axis II Personality Disorders stages as possible, without merely guessing. So remember, the aim is
(SCID-II). The SCID-II (First, Gibbon, Spitzer, Williams, & Benjamin, to say which emotion is being shown as soon as you recognize it by
1997) was used to assess diagnostic symptoms of BPD. Participants first
completed the SCID-II-PQ, a questionnaire with 119 items assessing the
1
presence (yes) or absence (no) of specific symptoms across the spec- For descriptive purposes, the frequency of Axis II diagnoses in the
trum of personality disorders. For the current study, items endorsed on the BPD group was examined (n 20). The most frequently diagnosed
SCID-II-PQ were further evaluated using the standard SCID-II interview. personality disorders were, in order, avoidant (45.0%), obsessive
This two-stage assessment process is commonly conducted, with studies compulsive (40.0%), paranoid (30.0%), schizoid (5.0%), schizotypal
suggesting a low false-negative rate for nonendorsed SCID-II-PQ items (15.0%), narcissistic (15.0%), histrionic (5.0%), dependent (5.0%), and
(Jacobsberg, Perry, & Frances, 1995). antisocial (5.0%).
650 LYNCH ET AL.

choosing one of the six emotions: fearful, sadness, disgust, surprise, to what extent between-groups differences in sensitivity could be ac-
happiness, or anger. Once you have given an answer, you can change counted for by a tendency to respond quickly with more errors, superior
your mind when you want to, and as often as you wish right up until affect recognition ability with full expression information, and differences
the end of the expression. Finally, for each face, you will also be asked in medication use and depressive symptom levels. Alpha levels were set at
to give a final answer. .05 (two-tailed) for all analyses.

Although this paradigm provided multiple indices for examining perfor-


mance, the principal measure of performance was the mean number of Results
stages required to achieve correct classifications of emotion. Secondary
Differences in Earliest Correct Response to Facial Affect
measures included the first stage at which any response was made and
performance accuracy for expressions at 100% expression. The first stage As hypothesized, the 2 (group) 6 (emotions) repeated mea-
at which any response was made was used to distinguish emotional sures mixed ANOVA revealed a significant multivariate main
sensitivity from response bias or impulsivity, which might lead some effect, F(5, 34) 23.42, p .0001, partial 2 .78. The Group
individuals to respond earlier or later without actually being able to identify
Emotion interaction was nonsignificant ( p .05). There were
the facial affect. Performance accuracy at 100% expression was used to
distinguish sensitivity to facial affect information from overall facial affect
significant main effects for both emotion, F(5, 190) 33.91, p
recognition ability. This task has been validated in studies of individuals .001, partial 2 .47, and group, F(1, 38) 5.98, p .05, partial
with psychopathic traits (Blair et al., 2001) and frontal variant frontotem- 2 .14. As hypothesized, the main effect for group indicated a
poral dementia (Lough, Treise, Blair, Watson, & Hodges, 2003). difference between groups in sensitivity (speed and accuracy) in
recognizing facial expressions, averaged across all emotions. The
Procedure main effect for emotion indicated that there was differential sen-
sitivity (ability to recognize emotion at low levels of intensity) in
Participants completed this experiment as part of a larger study exam- response to the different types of emotional faces. Differences in
ining emotional functioning and psychopathology. On the day of the response sensitivity to specific emotions are displayed in Figure 2.
experiment, participants began by providing written informed consent. Planned between-groups comparisons revealed a significant dif-
During this process, the experimenter remained in the room, and partici-
ference in sensitivity across all emotions between participants with
pants were actively encouraged to seek assistance regarding questions or
directions that were unclear. Next, participants completed questionnaires,
BPD (M 27.15, SD 4.85) and controls (M 30.90, SD
as well as prestudy Likert-type ratings on the extent to which they currently 4.86), t(38) 2.44, p .05. This difference reflects a large effect
felt stressed, had urges to harm themselves, and had urges to kill them- size (d 0.8). This suggests that, across all trials, participants with
selves (1 none; 7 extreme). Participants were seated in a comfortable BPD were able to correctly classify emotional faces presenting less
chair in front of a computer, oriented to the purpose of the study, and told affective information more accurately than were healthy controls.
that they could ask to take breaks during the study at any time. Next, planned between-groups comparisons were conducted in
To verify that participants knew how to use a mouse proficiently, all order to examine differences in sensitivity for specific emotions.
participants completed a 5-min mouse practice exercise that included These analyses revealed large effect sizes and significant between-
moving the mouse and clicking on variously sized and placed objects on group differences for anger, t(38) 3.02, p .01, d 1.0, and
the monitor screen. All participants successfully completed the mouse
happiness, t(38) 2.41, p .05, d 0.8. Medium to large effect
exercise and were then given instructions for the Multimorph Facial Affect
Recognition Task. Following the completion of this task, participants were
sizes and trends toward significant differences were found for
given a short break and returned to complete the SCID-II. At the conclu- sadness, t(38) 1.96, p .06, d 0.6, and fear, t(38) 1.85, p
sion of the SCID-II, participants completed poststudy ratings on a Likert-
type scale for the extent to which they currently felt stressed, had urges to
harm themselves, and had urges to kill themselves (1 none; 7
extreme). If a participant reported an increase in ratings of 2 or more points, 45
Average Number of Stages Until

or any rating above 0 of urges to harm or kill him- or herself, a suicide risk 40
and coping skills protocol was implemented by M. Zachary Rosenthal.
35
Correct Response

This protocol was used on six occasions in this study, each time with a
participant with BPD. Last, participants listened to a relaxation audiotape 30
with a female voice, were debriefed about the studys purpose, provided a 25 Controls
list of referrals for psychological services, and were compensated for their
time at a rate of $10 per hour. 20 BPD
15
Data Analytic Plan 10
The data analytic plan included four steps. First, before conducting 5
primary data analyses, distributions of the dependent variables (earliest
0
stage at which each emotion was correctly classified) were examined for
skewness and kurtosis, and Kolmogorov-Smirnov tests were conducted. All An Ds Sd Fr Sr Hp
All variables were normally distributed. Second, a 2 (group) 6 (emotion) Facial Affect
repeated measures mixed analysis of variance (ANOVA) was conducted to
examine the effects of group on the earliest stage at which facial emotional Figure 2. Sensitivity to facial affect across groups. Lower values reflect
expressions were correctly identified (sensitivity). Third, planned compar- faster correct responses to the target emotion expression. Error bars rep-
isons were conducted using independent samples t tests to more closely resent standard deviations. BPD boderline personality disorder; All all
examine specific between-groups differences in sensitivity. Finally, post stimuli; An anger; Ds disgust; Sd sadness; Fr fear; Sr surprise;
hoc ANOVAs and independent samples t tests were conducted to explore Hp happiness.
FACIAL EXPRESSION IN BPD 651

Table 2 between the BPD group (M 23.50, SD 8.98) and the control
Average Number of Stages Until Facial Expression Correctly group (M 22.50, SD 10.16) in the earliest stage at which
Identified happiness was incorrectly classified in nonhappiness trials ( p
.05).
Controls BPD

Emotion type M SD M SD p Differences in Accuracy of Response at Full Expression


To examine whether heightened sensitivity in the BPD group
All 30.90 4.86 27.15 4.85 .02
Anger 32.55 3.93 27.85 5.75 .01 was associated with the accuracy of facial emotional expression
Disgust 32.35 7.50 29.30 5.81 .16 recognition at 100% expression, a 2 (group) 6 (emotions)
Sadness 32.10 4.55 29.00 5.43 .06 repeated measures ANOVA was conducted on the number of
Fear 33.70 4.57 30.90 4.98 .07 correctly identified emotional expressions at 100% expression
Surprise 31.60 5.36 28.50 6.21 .10
Happiness 27.65 8.00 19.80 7.37 .02 across trials. A significant multivariate main effect was found, F(5,
34) 45.54, p .0001, partial 2 .87, but no significant
Note. Means reflect the average number of stages until correctly identi- interaction was found, F(5, 34) 1.29, p .05, partial 2 .16.
fying emotional expressions when the correct emotional expression was There was a significant main effect for emotion, F(5, 190)
also identified at 100% expression. BPD borderline personality disorder.
12.09, p .001, partial 2 .24, but not for group, F(1, 38)
0.45, p .05, partial 2 .01. Thus, an overall tendency to
accurately identify full expressions of emotion was not associated
.07, d 0.6. Medium effect sizes and no significant differences with BPD group status (see Table 3).
were found for surprise, t(38) 1.69, p .10, d 0.5, and
disgust, t(38) 1.44, p .16, d 0.5. As shown in Table 2, for Differences in Medication Use
each specific emotion significant between-groups differences re-
In addition, as a post hoc test to examine whether heightened
flected faster sensitivity in accurately classifying emotional faces
sensitivity in the BPD group was associated with differences in use
for participants with BPD compared with controls. Procedures
of psychotropic medication, chi-square analyses were conducted.
outlined by Rosenthal and Rubin (1982) were used to test the
More participants with BPD (65%) reported psychotropic medica-
relative magnitude of effects. Results indicate that the difference
tion use than did controls (10%), 2(1, N 40) 12.91, p .001.
between groups in sensitivity in correctly identifying anger relative
We therefore examined the earliest mean stage at which facial
to the difference between groups in identifying all other emotions
emotion was correctly identified as a function of medication usage.
was not significant ( ps .05). In addition, results indicate that the
Collapsing across emotion categories, there was no difference
difference between groups in sensitivity in correctly identifying
between the sensitivity of BPD participants currently prescribed
happiness relative to all other emotions was also not significant
medications (n 13, M 28.00, SD 5.28) compared with those
( ps .05).
not prescribed psychotropic medications (n 7, M 25.57, SD
3.78) in the earliest stage at which they correctly recognized
Differences in Earliest Incorrect Response emotions, t(18) 1.07, ns. Indeed, although not statistically
To examine whether heightened sensitivity in the BPD group different, unmedicated BPD participants correctly identified facial
was associated with a tendency to generally respond earlier with emotion slightly earlier than medicated BPD participants (d
more errors (i.e., to behave impulsively), a 2 (group) 6 (emo- 0.53; medium effect size).
tions) repeated measures ANOVA was conducted on the first stage
of inaccurate response across trials. A significant multivariate Differences in Depressive Symptoms
main effect was found, F(5, 34) 38.21, p .001, partial 2 A post hoc test to examine whether heightened sensitivity in the
.85, but no significant interaction was found ( p .05). There was BPD group was associated with depressive symptoms was con-
a significant main effect for emotion, F(5, 90) 21.96, p .001, ducted. The earliest mean stage at which facial emotion was
partial 2 .37, but not for group, F(1, 38) 0.02, p .05. Thus, correctly identified was examined as a function of the severity of
greater sensitivity to facial emotion expressions was not associated depressive symptoms on the HAM-D. Collapsing across emotion
with differentially earlier inaccurate responding in the BPD group. categories, there was no difference between the sensitivity of BPD
participants with a HAMD-D of 14 or greater (n 13, M 26.46,
Differences in Earliest Incorrect Response of Anger and SD 4.50) compared with those with a HAMD-D of 13 or less
Happiness (n 7, M 28.43, SD 5.56) in the earliest stage at which they
correctly recognized emotions, t(18) .86, ns. In addition, across
Because anger and happiness were the two emotions with sig-
all participants (n 40) and within the BPD group alone (n 20),
nificant between-groups differences in the earliest stage at which
no significant correlations were found between HAM-D scores and
emotions were correctly classified, differences in incorrectly clas-
the earliest mean stage at which facial emotion was correctly
sifying anger in nonanger trials and happiness in nonhappiness
identified ( ps .05)
trials were examined by means of post hoc independent samples t
tests. No differences were found between the BPD group (M
Discussion
25.95, SD 6.89) and the control group (M 28.41, SD 8.22)
in the earliest stage at which anger was incorrectly classified in This study demonstrated that, as faces morphed from neutral to
nonanger trials ( p .05). Similarly, no differences were found maximum-intensity emotional expressions, participants with BPD
652 LYNCH ET AL.

Table 3 clinical observations that individuals with BPD overreact to


Mean Percentage Accuracy of Facial Affect Recognition at minor emotional events, but if their accurate recognition of emo-
100% Expression Across Groups tional expressions leads them to experience more emotion, it may
exacerbate any emotional arousal they are already experiencing,
Controls BPD contributing to their problems with emotion regulation.
Emotion type M SD M SD
Findings suggest the possibility that emotional sensitivity
among individuals with BPD may not be valence specific. Observ-
All 83.80 7.42 85.40 6.15 ing subtle changes in the emotional expression of others, both
Anger 78.85 16.2 83.80 15.8 positive and negative, could contribute substantially to the emo-
Disgust 72.30 20.28 81.90 18.8
tional volatility of individuals with BPD. However, because the
Sadness 83.60 13.96 86.95 12.8
Fear 90.40 18.16 89.80 12.8 current study appears to be the first to suggest greater sensitivity to
Surprise* 85.55 12.67 76.30 15.8 positive affect in BPD, this finding should be regarded cautiously,
Happiness 99.00 4.47 99.15 3.80 pending replication. Future research should examine positively
valenced emotional expressions more comprehensively.
Note. BPD borderline personality disorder.
*
p .05. Our results can also be interpreted within frameworks that
emphasize the communicative functions of emotions (e.g. Frid-
lund, 1994). For example, angry facial expressions function to
generally correctly identified facial affect at an earlier stage than communicate action tendencies (i.e., I might attack you) and
did healthy controls. In addition, when examining specific emo- punish the social behavior of the receiver (e.g. Blair, 2003; Horst-
tions, participants with BPD were more sensitive than healthy mann, 2003). Indeed, rapid identification of others emotions may
controls regardless of the valence of the expressed emotion. These be advantageous, assuming the appraisal regarding the action
findings could not be explained by participants with BPD respond- tendency is also accurate. Consequently, considering that interper-
ing earlier and making more errors. Thus, greater sensitivity to sonal strife is characteristic of BPD, it may be that individuals with
facial emotional expressions was not associated with impulsive BPD are both more sensitive to low-intensity expressions of anger
and inaccurate responding in the BPD group. In addition, findings and also more likely to interpret such expressions as threats of
could not be explained by BPD participants having greater skill at attack or punishment from others. Such responses to perceived
classifying fully expressed (i.e., prototypic) emotional expressions. threat or punishment may contribute to their subsequent emotional
To our knowledge, this is the first study to examine sensitivity dysregulation and interpersonal problems.
to emotional facial expressions in BPD using facial affect mor- Considering the functional nature of emotional expression, our
phing technology. These findings are inconsistent with the per- findings are also interesting when contrasted with work with other
spective that BPD individuals are generally impaired at processing psychopathological samples. Using the same paradigm as in the
affective information or are specifically deficient at processing current study, Blair and colleagues have demonstrated that both
fear. For example, BPD individuals did not overidentify anger in psychopathic adults and children rated as exhibiting psychopathic
nonanger trials or happiness in nonhappiness trials compared with traits are characterized by a specific deficit in recognizing fear and
other groups, suggesting that they are not biased to read anger or sadness cues (Blair, 2003; Blair et al., 2001; cf. Kosson, Suchy,
happiness into all low-intensity facial expressions. Our findings Mayer, & Libby, 2002). Blair and colleagues have argued that
also contradict those of a previous study reporting that individuals these deficits relate to a lack of empathy in psychopathic individ-
with BPD are poor at recognizing fully expressed static facial uals (e.g. Blair et al., 2001). However, because empathy is a
expressions of anger, fear, and disgust (Levine et al., 1997). multidimensional construct that includes both accurate appraisal of
Results from the current study can be interpreted as consistent and capacity to experience others emotions (Eisenberg, 2000), it
with theoretical predictions contending that emotion dysregulation is premature to conclude that individuals with BPD have a height-
among BPD individuals is associated with faster latencies of ened capacity for empathy. In addition, although findings are not
response to emotional stimuli at low levels of emotional intensity entirely consistent across different studies, facial affect recognition
and that this exacerbates problems in emotion regulation (Linehan, deficits have also been reported in several other forms of psycho-
1993). Indeed, substantial evidence from prior research has sug- pathology, including nonparanoid subgroups of schizophrenia
gested that, in nonclinical samples, observing emotions in others is (Davis & Gibson, 2000), anorexia nervosa (Kucharska-Pietura,
often associated with the appearance of synchronous facial and Nikolaou, Masiak, & Treasure, 2004), bipolar disorder (Getz,
autonomic activity, interpreted as reflecting emotional contagion Shear, & Strakowski, 2003), alcohol dependence disorder (Frige-
(see Levenson, 1996, for a review). Moreover, individual differ- rio, Burt, Montagne, Murray, & Perrett, 2002), autism (Dawson,
ences in empathic accuracy have been reported to correlate posi- Webb, & McPartland, 2005), and, as noted below, in depression
tively with the degree of synchronous emotional responsiveness (e.g., Asthana, Mandal, Khurana, & Haque-Nizamie, 1998; Cooley
(McCarter, Ruef, & Levenson, 1996, as cited in Levenson, 1996). & Nowicki, 1989; Feinberg, Rifkin, Schaffer, & Walker, 1986;
This possibility appears consistent with prior research demonstrat- Persad & Polivy, 1993; Zuroff & Colussy, 1986). However, apart
ing that BPD individuals self-report greater affect intensity com- from studies of BPD, superior facial affect recognition is rarely
pared with non-BPD controls (Levine et al., 1997) and that self- reported for clinical groups, although individuals with paranoid
reports of greater negative affect intensity or reactivity are a strong schizophrenia exposed to natural facial expressions are one excep-
predictor of BPD symptoms (Cheavens et al., 2005; Rosenthal, tion (Davis & Gibson, 2000).
Cheavens, Lejuez, & Lynch, 2005). Thus, not only could a lower In addition, quick and accurate responding by the BPD group is
threshold for response help to provide a mechanism underlying the unlikely due to high depressive symptoms among the BPD group.
FACIAL EXPRESSION IN BPD 653

Prior research has shown that depressed patients exhibit a general facial affect, but they do suggest that any such biases do not fully
slowing of reaction time compared with nondepressed individuals explain the differences between BPD and non-BPD participants.
(Farrin, Hull, Unwin, Wykes, & David, 2003; Thomas, Goude- Additional studies using neutral images are warranted.
mand, & Rousseaux, 1999). In studies asking patients with depres- Finally, because medication was not controlled a priori and the
sion to rate facial expressions using paradigms similar to the one BPD group had significantly more medication usage than the other
used in our study, patients have been reported to be unimpaired groups, it is difficult to draw firm conclusions about the contribu-
(Archer, Hay, & Young, 1992; Feinberg et al., 1986; Gaebel & tion of medication to the findings. However, in examining the
Wolwer, 1992; Kan, Mimura, Kamijima, & Kawamura, 2004); to influence of psychotropic medication, there were no differences in
show recognition general deficits (Asthana et al., 1998; Cooley & the earliest stage in correctly recognizing emotions between BPD
Nowicki, 1989; Feinberg et al., 1986; Persad & Polivy, 1993; patients taking versus not taking medications.
Zuroff & Colussy, 1986); or to exhibit recognition deficits only for Despite these limitations, this is the first study to explore height-
specific types of facial expressions, such as happiness (Mandal & ened emotional sensitivity in participants with a BPD diagnosis
Bhattacharya, 1985; Suslow, Junghanns, & Arolt, 2001); happi- using dynamic laboratory measures. In addition, the use of the
ness, interest, and sadness (Rubinow & Post, 1992); or neutral SCID-II interview in determining eligibility for the various exper-
expressions (Bouhuys, Geerts, & Gordijn, 1999; Leppanen, Mild- imental groups is an improvement over several earlier studies that
ers, Bell, Terriere, & Hietanen, 2004). Thus, the fact that the BPD relied on self-report measures or clinician judgment. To further
group was more depressed yet more adept at recognizing happi- this line of research, future studies should more comprehensively
ness and faster at recognizing facial expression in general suggests examine the construct of sensitivity using multiple measures of
the possibility that emotional sensitivity in BPD may be indepen- emotional sensitivity (e.g., is BPD-heightened sensitivity specific
dent of current level of distress or depressive status. This argument to facial affect expressions, all emotional stimuli, or nonemotional
is further bolstered by post hoc analyses indicating that severity of stimuli as well?) In addition, future designs that more tightly
depressive symptoms neither across all participants nor within the control medication usage, reaction time, and overall processing
BPD group was associated with sensitivity to identifying facial speed would shed light on the current findings. Including a group
emotions correctly. of individuals with diagnosed PTSD, depression, other personality
To reduce subject burden, we did not obtain full SCID-I diag- disorders, and no personality pathology would allow investigators
noses on study participants. Consequently, we are unable to report to begin to untangle the effects of depression and personality
rates of comorbidity in the BPD sample, resulting in a potentially pathology on emotional sensitivity.
serious limitation for the study. For example, we do not know rates In summary, results demonstrate that individuals with BPD were
of posttraumatic stress disorder (PTSD), and given the high inci- significantly more likely to correctly identify facial affect at an
dence of childhood abuse or neglect in BPD (Zanarini et al., 1997), earlier stage, regardless of valence, relative to normal healthy
it is not possible to know whether emotional sensitivity findings controls. These findings have important implications for clinical
are related to a history of abuse. In addition, it is not possible to and theoretical observations suggesting that emotional sensitivity
conclude that effects are unique to BPD given that this was the in BPD individuals may be a core feature of the disorder.
only clinical group studied. Future research should include diag-
nostic assessments that will allow for comparisons between dif-
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