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When Social Inclusion Is Not Enough: Implicit Expectations of Extreme Inclusion in Borderline Personality Disorder
Abstract and Figures
Increasing evidence suggests that individuals with Borderline Personality Disorder (BPD) might feel rejected even when socially included by others. A psychological mechanism accounting for this response bias could be that, objective social inclusion violates BPD patients’ underlying implicit needs of “extreme” inclusion. Thus, this study investigated whether, during interpersonal exchanges, BPD patients report more rejection-related negative emotions and less feelings of social connection than controls, unless they are faced with conditions of extreme social inclusion.
Sixty-one BPD patients and sixty-one healthy controls completed a modified Cyberball paradigm. They were randomly assigned to a condition of ostracism, social inclusion or over-inclusion (a proxy for extreme social inclusion). They then rated their emotional states and feelings of social connection both immediately and 20 minutes after the game.
BPD patients reported greater levels of negative emotions than controls in both the ostracism and the inclusion conditions, but not when over-included. Further, only for BPD participants was over-inclusion associated with experiencing less negative emotions than the ostracism condition. Yet, BPD patients reported lower feelings of social connection than controls in any experimental situation.
Thus, in BPD, a laboratory condition of “over-inclusion” is associated with a reduction of negative emotions to levels comparable to those of control participants, but not with similar degrees of social connection. These results suggest that for BPD patients even “including contexts” activate feelings of rejection. Their implicit expectations of idealized interpersonal inclusion may nullify the opportunity of experiencing “real” social connection and explain their distorted subjective experiences of rejection.
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... As yet, no studies have used the IOS to operationalize intimacy (perceived parental closeness) in relation to adolescent personality pathology. However, researchers have utilized the IOS in studies of adults with BPD as a measure of connectedness with romantic partners following discussions of threatening topics (40), theoretical others following exposure to social inclusion, "over-inclusion, " and ostracism conditions (41), and theoretical others following participation in multisensory perceptual self-other-distinction tasks (i.e., facial morphing task and synchronous or asynchronous interpersonal multisensory stimulation) (42). ...
... Importantly, although higher scores could perhaps be interpreted as an inflated sense of closeness that is driven by impairments in self-other distinction, a key feature of BPD, previous studies employing the IOS with individuals with BPD have demonstrated that BPD patients reported less feelings of closeness than their healthy control counterparts. Specifically, individuals with BPD perceived less social connection to theoretical others irrespective of being in a social inclusion, "over-inclusion," or ostracism condition (41), and a sharper decline in feelings of closeness to romantic partners when they were observed to demonstrate a heightened stress response (40). ...
According to dimensional models of personality pathology, deficits in interpersonal (intimacy and empathy) and self (identity and self-direction) function (Criterion A) are core to all personality disorders. These aspects of personality functioning (Criterion A) have seldom been evaluated for how they might relate to one another in the context of personality pathology in adolescents. Moreover, the use of performance-based measures to evaluate aspects of Criterion A function remains an untapped resource. Therefore, the present study aimed to evaluate relations between two features of Criterion A, maladaptive intimacy and maladaptive (or diffused) identity, in adolescence. For intimacy, we leverage a performance-based approach to studying intimacy, operationalized in a developmentally relevant way (perceived parental closeness). For identity, we rely on a validated self-report measure of identity diffusion. We examined the relationship between these features with each other and their relations with borderline features. Additionally, we explored whether identity diffusion mediated the expected relationship between perceived parental closeness and borderline features. We hypothesized that greater distance in perceived parental closeness would be associated with higher levels of borderline features, as well as higher levels of identity diffusion, and that identity diffusion would account for the relationship between intimacy and personality pathology. The sample included 131 inpatient adolescents ( M age = 15.35, 70.2% female). Results indicated that intimacy, operationalized as perceived parental closeness, with both mothers and fathers was significantly associated with levels of identity diffusion and borderline features. In addition, greater feelings of closeness with parents were associated with lower severity of borderline features via healthier identity function. Implications of the results, limitations, and future directions are discussed.
... Accordingly, BPD individuals, as well as individuals high in borderline traits, have an unstable sense of self and others (Kernberg, 1995), suffer from extreme rejection sensitivity (Berenson et al., 2011;, feel excluded even in inclusive situations (De Panfilis et al., 2015) and tend to interpret neutral situations (King-Casas et al., 2008) and stimuli (Richetin et al., 2018) as malevolent. Moreover, since BPD is often related to traumatic experiences (Luyten et al., 2020), with subsequent impairment in mentalization (Fonagy et al., 2016) and emotional vulnerability (Chapman et al., 2014), it is possible that suspiciousness may arise from these trauma-related mechanisms, as suggested by a recent review (Bloomfield et al., 2021). ...
Recent diagnostic developments suggest that paranoia is a transdiagnostic characteristic common to several personality disorders rather than a personality disorder per se. Nonetheless, empirical literature fails to provide comprehensive and univocal findings on whether and how paranoid presentations relate to different personality disorders. In the present scoping review, we map the empirical literature on paranoid presentations in personality disorders, considering the entire spectrum of paranoid manifestations (i.e., the paranoia hierarchy). In selecting original quantitative studies on paranoid presentations in personality-disordered patients, we screened 4,433 records in PsycArticles, PsycInfo and PUBMED. We eventually included 47 eligible studies in the review. Our synthesis indicates consistent empirical evidence of a wide range of paranoid presentations in Paranoid, Schizotypal and Borderline personality disorders. Conversely, little empirical literature exists on paranoid presentations in other personality disorders. Preliminary findings suggest broad-severity paranoid presentations, ranging from milder to severe forms, in Paranoid, Schizotypal and Borderline personality disorders. There is also some evidence of milder forms of paranoia in Avoidant, Antisocial and Narcissistic personality disorders. Conversely, there is poor evidence of paranoid presentations in Schizoid, Histrionic, Dependent or Obsessive-compulsive personality disorders. Research gaps and recommendations for improving empirical research on paranoid presentations in personality disorders are discussed.
... In contrast, in patients with BPD psychosocial stress often leads to reactive fight-offlight behaviour, which is characterised by the inhibition of prosocial behaviour, lowered empathy and aggressive action tendencies [12,20]. Due to the biased perception of social participation in BPD, an overinclusion condition has been established as the preferred control condition in the Cyberball task as opposed to equal inclusion to overcome exclusion hypersensitivity [14,21]. ...
Stressful social situations like social exclusion are particularly challenging for patients with borderline personality disorder (BPD) and often lead to dysfunctional reactive behaviour of aggression and withdrawal. The autonomous signature of these core symptoms of BPD remains poorly understood. The present study investigated the parasympathetic response to social exclusion in women with BPD (n = 62) and healthy controls (HC; n = 87). In a between-subjects design, participants experienced objective social exclusion or overinclusion in the Cyberball task, a virtual ball-tossing game. Need threat scores served as individual measures of perceived exclusion and the resulting frustration of cognitive–emotional needs. Five-minute measurements of high-frequency heart rate variability (HF-HRV) at three time points (before, during, after Cyberball) indicated parasympathetic tone and regulation. We observed a trend towards lowered baseline HF-HRV in BPD vs. HC in line with previous findings. Interestingly, the parasympathetic response of patients with BPD to objective and perceived social exclusion fundamentally differed from HC: higher exclusion was associated with increased parasympathetic activation in HC, while this autonomic response was reversed and blunted in BPD. Our findings suggest that during social stress, the parasympathetic nervous system fails to display an adaptive regulation in patients with BPD, but not HC. Understanding the autonomous signature of the stress response in BPD allows the formulation of clinically relevant and biologically plausible interventions to counteract parasympathetic dysregulation in this clinical group.
... Studies exploring state rejection sensitivity (via inducing social rejection) in BPD populations report less consistent findings. For example, in some studies, adult BPD patients and community samples with high BPD features report higher levels of negative affect and anxiety following social rejection relative to their healthy counterparts (Beeney et al., 2014;De Panfilis et al., 2015). A recent study also found that BPD pathology in undergraduate university students (aged 18-24 years) was associated with greater negative mood and hostility during a rejection but not an inclusion induction condition (Richmond et al., 2020). ...
Application of emotion regulation strategies might be susceptible to the context of social rejection for individuals with borderline personality disorder (BPD). This study compared the ability of 27 outpatient youths (15-25 years old) with early-stage BPD and 37 healthy controls (HC) to apply expressive suppression and cognitive reappraisal in standard and socially rejecting laboratory contexts. BPD youths were largely as able as HCs to regulate negative affect across instruction and contexts. However, cognitive reappraisal in the context of social rejection heightened BPD negative facial expression relative to HCs. Thus, while BPD emotion regulation ability was largely normative, cognitive reappraisal might be ineffective in the context of social rejection for this group, with social rejection acting as an accelerant that heightens the expression of negative affect. Given the common experience of perceived and actual social rejection for this group, clinicians should carefully consider treatments that include cognitive reappraisal strategies because they might be contraindicated.
... The ball receiving rates were decided based on previous literature on various psychiatric conditions, where overinclusion was rated as a specific social trigger for participants. In contrast, average inclusion might not be sufficient due to the possible tendency to expect an exclusion in ED population, or the negative interpretation of positive evaluations reported in the previous literature [9,41,49,50]. ...
(1) Background: the investigation of how interpersonal functioning affects eating psychopathology has been receiving increasing attention in the last decade. This study evaluates the impact of virtual social inclusion or ostracism on emotions, perceived stress, eating psychopathology, and the drive to binge or restrict in patients across the eating disorder spectrum. (2) Methods: a group of 122 adolescent and adult females with different eating disorder diagnoses were compared to 50 healthy peers with regards to their performance on, and responses to the Cyberball task, a virtual ball-tossing game. Each participant was randomly assigned to playing a social inclusion or a social exclusion block of the Cyberball task and completed self-report assessments of emotions, perceived stress and urge to restrict/binge before and after the task. (3) Results: patients with anorexia nervosa showed a more negative impact on psychological well-being evaluated with the need threat scale after the excluding block, while patients with bulimia nervosa reported more negative effects after the overincluding condition. Patients with binge eating disorder showed a reduction in specific negative emotions after the overincluding block, unlike all other participants. (4) Conclusions: findings show significant correlations between restraint thoughts in patients with bulimia nervosa and binge thoughts in patients with binge eating disorder after being exposed to the inclusion condition. Different reactions in cognitive and emotional states of patients with eating disorders after different interpersonal scenarios confirm the impact of inclusive or exclusive relationships on eating psychopathology, with specific and different responses across the eating disorder spectrum, that have been discussed, linked to their eating behavioral cognition.
... In individuals with emotionally unstable personality disorder, they can manifest as frantic efforts to avoid abandonment resulting from inabilities to regulate the self and relationships with others, particularly closeness and distance (Caligor and Clarkin, 2010). Study participants with emotionally unstable personality disorder were so sensitive to rejection that they did not feel part of the group even when they were "over-included" in an experimental ball game paradigm (De Panfilis et al., 2015). Hence, feelings of social (dis)connectedness arose from the persons' perception and interpretation of the situation rather than from its objective characteristics. ...
Background: Loneliness is a major public health issue and the identification of risk factors is crucial for prevention and intervention. While previous research has often investigated sociodemographic and external factors (e.g., living situation), personality variables received less attention. This study aimed to harness recent advances in the dimensional assessment of personality pathology to expand knowledge about psychological determinants of loneliness in the population. Methods: We surveyed a sample representative of the German population concerning age, gender, and level of education (N = 2412) using measures of loneliness (UCLA 3-item loneliness scale), personality functioning (12-item version of the OPD-Structure Questionnaire OPD-SQS), and mental distress (PHQ-4). We explored the relevance of personality functioning for loneliness in a multivariate linear regression analysis and in a theoretically-based path model in which we tested loneliness as the mediator between personality functioning and mental distress. Results: In the regression analysis, personality functioning showed strong associations with loneliness (β = 0.48, p < .001) (within a model that included gender, age, living situation, income, education, and partnership). The mediation model fit the data well and loneliness mediated 39.9% of the total effect of personality functioning on distress. Limitations: The present findings are based on cross-sectional survey data. Conclusions: This study gives insight into previously understudied individual differences shaping feelings of loneliness and mental health outcomes. It suggests that deficits in personality functioning independently aggravate the risk of experiencing loneliness, hence the conception of risk factors for loneliness should be expanded to include personality variables.
... Obviously, the two are not the same, and perceptions of exclusion may shape the interpersonal reaction to exclusion (Smart Richman & Leary, 2009). The objectively same situation may be perceived as excluding by one individual but not by another, and the same perception of an exclusion situation may still cause one individual to react with greater pain than the other (e.g., De Panfilis et al., 2015). However, differences in perceptions of exclusion were likely captured in assessing individual differences; for instance, in rejection sensitivity. ...
Unlike one-time lab manipulations of exclusion, in real life, many people experience exclusion, from others and from groups, over extended periods, raising the question of whether individuals could, over time, develop hypo- or hypersensitive responses to chronic exclusion. In Study 1, we subjected participants to repeated experiences of inclusion or exclusion (three Cyberball games, time lag of three days, N = 194; 659 observations). We find that repeatedly excluded individuals become hypersensitive to inclusion, but not to exclusion. Study 2 ( N = 183) tested whether individuals with chronic experiences of real-world exclusion show hypo- or hypersensitive responses to a novel episode of exclusion. In line with Study 1, exclusion hurt to the same extent regardless of baseline levels of chronic exclusion in daily life. However, chronically excluded individuals show more psychological distress in general. We discuss theoretical and practical implications for dealing with chronically excluded individuals and groups.
Laughter plays an important role in group formation, signaling social belongingness by indicating a positive or negative social intention towards the receiver. In adults without autism, the intention of laughter can be correctly differentiated without further contextual information. In autism spectrum disorder (ASD), however, differences in the perception and interpretation of social cues represent a key characteristic of the disorder. Studies suggest that these differences are associated with hypoactivation and altered connectivity among key nodes of the social perception network. How laughter, as a multimodal nonverbal social cue, is perceived and processed neurobiologically in association with autistic traits has not been assessed previously. We investigated differences in social intention attribution, neurobiological activation, and connectivity during audiovisual laughter perception in association with the degree of autistic traits in adults [N = 31, Mage (SD) = 30.7 (10.0) years, nfemale = 14]. An attenuated tendency to attribute positive social intention to laughter was found with increasing autistic traits. Neurobiologically, autistic trait scores were associated with decreased activation in the right inferior frontal cortex during laughter perception and with attenuated connectivity between the bilateral fusiform face area with bilateral inferior and lateral frontal, superior temporal, mid-cingulate and inferior parietal cortices. Results support hypoactivity and hypoconnectivity during social cue processing with increasing ASD symptoms between socioemotional face processing nodes and higher-order multimodal processing regions related to emotion identification and attribution of social intention. Furthermore, results reflect the importance of specifically including signals of positive social intention in future studies in ASD.
Objective:
Borderline Personality Disorder (BPD) diagnosis comprises several constellations of trait, neurocognitive and psychosocial alterations. Dimensional models of psychopathology provide new opportunities to parse heterogeneity and create a stronger interface between individual characterisation and psychosocial outcomes. However, dimensional models have focused on either traits or neurocognitive features, lacking integration to capture the multifaceted nature of BPD.
Method:
We assessed 100 participants with BPD using a combination of tools stemming from trait (Alternative Model for Personality Disorders) and neurocognitive models (Research Domain Criteria; RDoC) to examine if trait-derived subgroups display distinctive social-processing and psychosocial profiles. We used two complementary analytical approaches: person-centered (k-means clustering) and construct-based (multiple-factor analysis).
Results:
Our person-centered approach identified four subgroups with separable internalizing, detached, externalizing, and low psychopathology trait-profiles. These profiles revealed distinctive patterns of affiliation, emotion recognition and mentalisation performance in RDoC tasks, and psychosocial measures of quality of life and social connectedness. RDoC-based measures showed close construct proximity with negative affectivity, disinhibition, and antagonism trait domains, relative to the detachment domain, which had close proximity with self-knowledge.
Conclusions:
Altogether, findings support consilience between trait-based and neurobiological frameworks and suggest that trait models are useful to parse BPD heterogeneity leading to unique social functioning profiles.
This study examined the psychometrics of the Structured Clinical Interview for DSM-IV Personality Disorders Personality Questionnaire (SCID-IIP) self-report personality questionnaire. The responses to the instrument were found reliable and evidenced good self-other convergence. Correlations with external criteria showed the SCID-IIP to contain broadpersonological information. The scale's basis in DSM-IV nosology makes it a potentially important tool for clinical research.
We examined 120 Cyberball studies (N = 11,869) to determine the effect size of ostracism and conditions under which the effect may be reversed, eliminated, or small. Our analyses showed that (1) the average ostracism effect is large (d > |1.4|) and (2) generalizes across structural aspects (number of players, ostracism duration, number of tosses, type of needs scale), sampling aspects (gender, age, country), and types of dependent measure (interpersonal, intrapersonal, fundamental needs). Further, we test Williams's (2009) proposition that the immediate impact of ostracism is resistant to moderation, but that moderation is more likely to be observed in delayed measures. Our findings suggest that (3) both first and last measures are susceptible to moderation and (4) time passed since being ostracized does not predict effect sizes of the last measure. Thus, support for this proposition is tenuous and we suggest modifications to the temporal need-threat model of ostracism.
Ostracism is such a widely used and powerful tactic that the authors tested whether people would be affected by it even under remote and artificial circumstances. In Study 1, 1,486 participants from 62 countries accessed the authors' on-line experiment on the Internet. They were asked to use mental visualization while playing a virtual tossing game with two others (who were actually computer generated and controlled). Despite the minimal nature of their experience, the more participants were ostracized, the more they reported feeling bad, having less control, and losing a sense of belonging. In Study 2, ostracized participants were more likely to conform on a subsequent task. The results are discussed in terms of supporting K. D. Williams's (1997) need threat theory of ostracism.
The degree to which self-esteem hinges on feedback in a domain is known as a contingency of self-worth, or engagement. Although previous research has conceptualized engagement as stable, it would be advantageous for individuals to dynamically regulate engagement. The current research examined whether the tendency to disengage from negative feedback accounts for variability in self-esteem. We created the Adaptive Disengagement Scale (ADS) to capture individual differences in the tendency to disengage self-esteem from negative outcomes. Results demonstrated that the ADS is reliable and valid (Studies 1 and 2). Furthermore, in response to negative social feedback, higher scores on the ADS predicted greater state self-esteem (Study 3), and this relationship was mediated by disengagement (Study 4). These findings demonstrate that adaptive disengagement protects self-esteem from negative outcomes and that the ADS is a valid measure of individual differences in the implementation of this process.