Borderline Personality Disorder and relationships

Today, we look at three studies of relationships in people with Borderline Personality Disorder. First, van Schie, Matthews, Marceau, Römer & Grenyer (2024) published “Affective and Neural Mechanisms of How Identity Dysfunction in Borderline Personality Disorder May Interfere with Building Positive Relationships” in Personality Disorders: Theory, Research, and Treatment. 

Here are some excerpts (the full text is available):

Individuals with borderline personality disorder (BPD) often hold pervasive and negative self-views and experience feelings of low connectedness toward others despite effective treatment. This study aimed to identify neural and affective mechanisms of identity disturbance in BPD that contribute to difficulties in relating to others. Participants diagnosed with BPD (N = 34) and nonclinical controls (NCC; N = 35) completed a within-subject social feedback task inside a magnetic resonance imaging scanner. Participants received character evaluations, supposedly from a panel of three members who provided either predominantly negative, intermediate, or positive feedback. Multilevel analysis and event-related functional magnetic resonance imaging analysis compared the BPD and NCC group on mood, affiliation, and neural responses to the feedback and the panel. Results indicate that people with BPD had more negative self-views and reported lower mood after negative and intermediate feedback compared to NCC. People with BPD also felt less close to the member providing predominantly positive feedback compared to NCC, which appeared to be mediated by degree of fearful attachment. People with BPD showed altered bold responses to social feedback in temporal parietal junction and the anterior cingulate cortex compared to NCC. Findings indicate that people with BPD experience pervasive negative self-views that may interfere with forming relationships. New interactions may reinforce a fearful pattern of relating as existing (negative) views of the self are activated and subject to confirmation. These complexities have important clinical implications for the therapeutic alliance. Balancing a supportive and expressive stance may foster the therapeutic alliance while challenging negative self-views. 

We found that people with BPD felt less affiliated with others overall. It is understood that people with BPD can on the one hand feel intimately close with others and on the other hand can feel disconnected and lonely (Jørgensen & Bøye, 2022; Miller et al., 2020). This difficulty in relating to others is thought to stem from a lack of self-feeling that necessitates people with BPD to either merge themselves with others’ states or maintain a distance out of a fear of being engulfed by others (De Meulemeester et al., 2021; Deutsch, 1942; Jørgensen & Bøye, 2022; Miller et al., 2020). Our finding extends a previous finding that people with BPD prefer to keep physical distance from unknown others (Fineberg et al., 2018). In the situation of receiving personal feedback from unknown others, it may be likely that people with BPD maintain an emotional distance from others. Decreased activation in the posterior TPJ to social feedback may further indicate that people with BPD have difficulty with distance and closeness to others (De Meulemeester et al., 2021).

However, people with BPD did distinguish between the three panel members and felt less close to the person providing positive feedback about them as compared to NCC. Previous studies indicate that people with BPD may have particular difficulty internalizing positive experiences (Liebke et al., 2018; Miller et al., 2020). It may be that for people with BPD positive feedback does not recruit processes of self-relevance to the same degree as for people without this diagnosis, or that people with BPD are hypervigilant to questioning the intentions of the person providing positive feedback.

In this study, we found that people prefer feedback that is in line with how they see themselves (i.e., applicability) irrespective of whether the feedback is positive or negative. Receiving information that confirms what one thinks establishes a sense of continuity (Swann & Brooks, 2012). For people with BPD, receiving positive feedback may have been very foreign from their negative self-view and therefore hard to integrate and relate to. Despite negative feedback being in line with what is expected, it still had a detrimental effect on mood in individuals with BPD compared to people without a diagnosis as observed in the present study as well as in other studies (Miano et al., 2013; van Schie et al., 2020).

We observed a mediation effect of fearful attachment indicating that those with BPD are more likely to view themselves and others as negative and thereby find it harder to relate to positive others. This finding in the context of new interactions points to the pervasiveness of these patterns of relating (Grenyer & Marceau, 2022). The observation that people may prefer to maintain a negative self-view and distance themselves from positive others may be in line with the idea of epistemic freezing (Fonagy & Allison, 2014). However, this finding needs further replication and explicit testing of the mediation effect.

These difficulties in relationships will also be experienced in the therapeutic alliance. This has specific implications for the complex task of establishing a therapeutic alliance when working with patients with BPD, as providing overly positive feedback may inadvertently create a distance between patient and clinician. A crucial task for clinicians concerns the establishment of the therapeutic alliance early in treatment. Being authentic in understanding the struggles of the person with BPD may be key to building a therapeutic alliance wherein negative self-views may be challenged.

I used more from this study because I found it intriguing, first in suggesting that people with BPD are very conflicted by positive feedback and this may have important implications for the therapeutic alliance. Second, I found the idea of epistemic freezing fascinating. Because they used fMRI, the sample is small but the findings potentially important. Next, Gregorini, De Carli, Parolin, Petilli, Konvalinka & Preti (2024) published “Stable Asynchrony? Association between borderline personality traits and interpersonal asynchrony” in Personality Disorders: Theory, Research, and Treatment.  Here’s the edited abstract:

Interpersonal coordination processes facilitate interpersonal synchrony through a continuous mutual adaption and corepresentation of self and others’ actions. Such a process has been found to enhance prosocial behaviors, affiliation, and trust. While research has investigated the general underlying cognitive and social mechanisms that facilitate interpersonal synchrony, much less is known about how interpersonal impairments influence it in various psychopathological conditions—such as borderline personality disorder (BPD). In this study, we investigated the role of the social cognitive processes of individuals with high BPD traits during a synchronized interaction task. Participants (N = 206) were recruited from the general population. BPD traits were assessed, and interpersonal synchrony was measured with a finger-tapping task. Participants were instructed to interact with a virtual partner (VP) that varied its adaptivity level in response to their taps across different conditions of adaptivity (α), ranging from nonadaptive to overly adaptive. After each interaction, the perception of synchrony and affect were assessed. Results showed an overall main significant effect of the adaptivity of the VP on interpersonal synchrony and the interaction experience, such that when VP adaptivity increased, asynchrony and perceived synchrony decreased. High levels of BPD traits were associated with higher asynchrony and variability, depending on the level of VP adaptivity, and an overall more negative perception of synchrony and affect. These findings show that high BPD traits are associated with reduced interpersonal synchrony during interaction. Consistent with these findings, interventions might consider the potential role of interpersonal synchrony in building the therapeutic relationship. 

This is a much larger sample but also looks at the therapeutic relationship. Here the finger tapping allows assessment of adaptivity; the finding that those with higher BPD traits show both higher asynchrony and variability is not surprising and their overall more negative perception of synchrony and effort is consistent with van Schie et al. Finally, Mehrotra, Raudales, Epshteyn, Dixon-Gordon, Peters & Weiss (2024) published “Prospective Relationships between Positive Emotion Dysregulation and Borderline Personality Disorder Features among Women Experiencing Intimate Partner Violence” in Personality Disorders: Theory, Research, and Treatment.  Here’s the edited abstract:

Emotion dysregulation is a core feature of borderline personality disorder (BPD). However, there is a dearth of literature examining the association between the dysregulation of positive emotions and BPD. The present study assesses the reciprocal and longitudinal associations between positive emotion dysregulation and BPD features. Participants were 149 community women currently experiencing intimate partner violence and using substances (Mage = 40.3, 30.8% Black). BPD was assessed at baseline via a clinician-administered diagnostic interview. Participants self-reported on positive emotion dysregulation and BPD features at baseline and 1-month follow-up sessions. Positive emotion dysregulation did not significantly predict BPD features at 1-month follow-up when controlling for initial BPD features (β = −.09, SE = 0.07, p = .21, confidence interval [CI] [−0.23, 0.10]). However, BPD features did significantly predict positive emotion dysregulation at 1-month follow-up, when controlling for initial positive emotion dysregulation (β = .25, SE = 0.10, p = .01, CI [0.07, 0.44]). This study offers initial insight into the nature of the association between BPD and positive emotion dysregulation over time among women experiencing intimate partner violence and using substances. Findings highlight the role of BPD features in the exacerbation of positive emotion dysregulation, which may inform targeted assessments and treatments in this area. 

Since the first two studies highlighted the complex relationship between having BPD symptoms and getting positive feedback, I though this one was consistent. It seems that dysregulation of positive affect is exacerbated by BPD features. Taken together, each of these studies makes clear the importance of attending to positive as well as negative affect in working with clients who have BPD features.