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When Social Inclusion Is Not Enough: Implicit Expectations of Extreme Inclusion in Borderline Personality Disorder

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Chiara De Panfilis at University of Parma
Chiara De Panfilis
Paolo Riva at Università degli Studi di Milano-Bicocca
Paolo Riva
Emanuele Preti at Università degli Studi di Milano-Bicocca
Emanuele Preti
Chiara Cabrino
Chiara Cabrino
Chiara Cabrino
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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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... consequently, while healthy individuals are affected by social exclusion because this condition violates their implicit expectation of being included by others, people with BPD might react as if they were ostracized even in inclusion scenarios because fair inclusion violates their implicit expectations for extreme social inclusion. therefore, evaluating whether BPD patients respond with lower negative emotions to the cyberball overinclusion as compared to the inclusion and ostracism conditions can allow investigating whether this patient population relies on a higher threshold of social attention from others, which can result in rejection feelings even in fairly including scenarios (De Panfilis et al., 2015). therefore, this systematic review focused on the empirical studies that adopted the overinclusion condition in cyberball. ...
... eight studies used a between-group design, fourteen were within-group studies, and twelve had a mixed study design (between-within-subject study). Six studies tested cyberball effects on clinical populations (De Panfilis et al., 2015;ghosh, 2021;Meneguzzo et al., 2020;2022;weinbrecht et al., 2018, 2021, and six studies investigated the neural correlates elicited by the cyberball paradigm (cheng et al., 2019;ikeda & takeda, 2021;Kawamoto et al., 2012;Niedeggen et al., 2014;weinbrecht et al., 2018, 2021. Four studies structured the cyberball manipulation as a seamless succession of all the experimental conditions resulting in rounds of inclusion mixed with overinclusion, rounds of inclusion mixed with exclusion, or a gradual increase or decrease of tosses to obtain social inclusion or exclusion (cheng et al., 2019;ho et al., 2014;okanga, 2021;Peake, 2016). ...
... compared to inclusion, all the nineteen studies reported that overinclusion is associated with the perception of getting more ball tosses. twelve of them (50%) reported also improved psychological needs and mood of the participants (anderson, 2011;Burgdorf et al., 2016;De Panfilis et al., 2015;erel et al., 2021;ikeda & takeda, 2021;Kwok et al., 2018;Niedeggen et al., 2014;Schrantz et al., 2021;van Beest et al., 2011;van Bommel et al., 2016;venturini et al., 2016;weinbrecht et al., 2018). one study associated these positive emotional effects with social pain reduction (ikeda & takeda, 2021), and another with a physiological state typical of relaxation (Burgdorf et al., 2016). ...
On the other side of ostracism: a systematic literature review of the cyberball overinclusion condition
Article
Full-text available
  • Apr 2024
Cyberball, the paradigm developed by Kipling D. Williams and colleagues (2000) to study ostracism, initially counted three experimental conditions: inclusion, exclusion, and overinclusion. The least known of these conditions is overinclusion, a social interaction characterized by excessive social attention (rather than fairness or no attention). This review provides an overview of original empirical studies implementing the overinclusion condition since its development. Following the PRISMA 2020 criteria, studies were drawn from four electronic databases (PubMed, Springer, PsycINFO, Web of Science), and Google Scholar was screened as a web-based academic search engine. In all, 33 studies met the inclusion criteria. Included studies described overinclusion specificities compared with exclusion and inclusion conditions, its effects in paradigms other than Cyberball, brain correlates associated with overinclusion, and its impact on clinical populations. 26 studies compared the inclusion and overinclusion conditions. 20 revealed significant differences between the two conditions, and 13 observed better mood and higher psychological needs satisfaction associated with the overinclusion condition. Studies investigating neural correlates revealed dACC involvement, P3 reduction, and P2 increase during overinclusion, supporting the idea of an ameliorative effect induced by the over-exposition to social stimulation. Findings on clinical populations suggest that overinclusion may help detect the social functioning of patients with psychological impairment. Despite the heterogeneity of the studies, our results showed that overinclusion can be associated with ameliorative psychological functioning. However, implementing standard guidelines for overinclusion will help provide a more thorough investigation of the psychological consequences of receiving excess social attention.
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... In this virtual ball-tossing game, the proportion of ball tosses the participant receives while exchanging ball throws with co-players induces social exclusion and inclusion. In BPD, higher levels of experienced social exclusion were found across most experimental conditions including even conditions with an overinclusion of the participants or ball-tossing sequences that were determined by predefined rules instead of by the intentions of the alleged co-players [12,16,17]. These findings indicate that not only differences in perceptions of rejection but also of acceptance are important for understanding interpersonal difficulties in BPD patients. ...
... Therefore, our data underscore the importance that the focus of therapeutic approaches for the treatment of interpersonal difficulties in BPD should not be limited to coping with rejection but should also include a strengthening of the perception and enjoyment of being accepted. Furthermore, prior findings suggest altered social norms in BPD in form of higher expectations regarding inclusion and fairness [17,91]. In this context, the lower effect of acceptance could also be explained by altered expectations and an idealized need for belonging in social relationships in BPD. ...
You say it‘s not me: the influence of offering external explanations of rejection and acceptance behavior on the perception of benevolence in borderline personality disorder
Article
Full-text available
  • Nov 2024
Background Interpersonal impairments in patients diagnosed with borderline personality disorder (BPD) are characterized by the fear of being rejected and high levels of loneliness. Potential underlying factors are alterations in the processing of social interactions and the associated perceptions of social partners. In this regard, BPD patients tend to attribute the cause of negative rather than positive events to their own person and to perceive others as less trustworthy than healthy controls (HCs). To date, no study has investigated whether the effect of experimentally influenced causal attributions of social interactions on the perception of a social partner differs between BPD patients and HCs. Methods A new virtual reality paradigm was developed to investigate the perception of benevolence following the induction of social rejection and acceptance, while experimentally manipulating whether an external cause for this behavior was provided. The data of 62 participants (32 HCs, 30 BPD patients) were analyzed using linear mixed-effects models. Associations of benevolence ratings with attributional style, rejection sensitivity, self-esteem, childhood trauma, and loneliness were investigated via correlational and multiple linear regression analyses. Results Across both groups, a social partner was rated as less benevolent following rejection than following acceptance. An external explanation mitigated this negative effect of rejection. Overall, benevolence ratings were lower in BPD patients than in HCs. This group difference was stronger following acceptance than following rejection. Independent of acceptance and rejection, an external explanation was associated with a higher level of benevolence only in the HC group. No associations of the effects of the experimental conditions with attributional style, childhood trauma, rejection sensitivity, self-esteem, or loneliness were found. Conclusion Our findings indicate that acceptance and provided external explanations for rejection have a less positive impact on the perception of a social partner’s attitude toward oneself in BPD patients than in HCs. More research is needed to identify predictors of benevolence perception and which steps of social information processing are altered. The therapeutic implications include the importance of strengthening the perception and enjoyment of being accepted as well as improving the mentalizing ability of BPD patients.
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... Alternatively, it could be that such individuals may have a dysfunctional threshold for acceptance similar to that experienced by those with borderline personality disorder (BPD). For example, De Panfilis et al. (2015) found that those with BPD can still report significant distress even when included (vs excluded) in a game of Cyberball (a virtual ball toss game), with such effects dissipating within an overinclusion condition (i.e., passed the ball 45% of the time by 2 computer characters). Moreover, Sharma and Dhar (2024, p. 7) recently argued that some people may experience ostracism hypersensitivity whereby they "anxiously expect ostracism, readily misidentify social cues to be exclusionary in nature, and perceive ostracism in non-ostracizing situations". ...
... However, the method adopted in this study does not allow us to consistently discriminate between such hypotheses which could all be plausible. One avenue that future studies may consider exploring is that of using Cyberball overinclusion studies (e.g., De Panfilis et al., 2015). ...
Unraveling Perceived Ostracism: The Role of Antagonistic Traits and Attachment Orientation
Article
Full-text available
Perceived ostracism (e.g., feeling ignored and excluded) can lead to psychological distress. There has been little empirical research into the types (profiles) of people more likely to perceive ostracism. The present study (N = 604) used latent class analysis (LCA) to (a) explore classes based on antagonistic traits (narcissism, machiavellianism, psychopathy, and sadism) while controlling for attachment orientation (attachment anxiety and attachment avoidance) and (b) examine whether such classes could reliably differentiate levels of self-reported perceived ostracism. We extracted five classes: (a) Average Low, (b) the Non-Antagonisers, (c) Average High, (d) Spiteful Manipulators, and (e) the High Antagonisers. Those in the High Antagonisers class reported significantly higher levels of perceived ostracism compared to all other classes. No other differences between classes were observed. There were also significant positive relationships for avoidant and anxious attachment on perceived ostracism, respectively. This study provides new insight into the profiles of individuals who may be more likely to perceive ostracism. However, further research is needed to explore the association between personality and perceived ostracism. Researchers may consider measuring the potential outcomes following perceived ostracism for such groups and/or design potential interventions for those at risk of such experiences.
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... In addition to the number and frequency of social relationships (i.e., structural social connectedness) for those with BPD, research has also examined actual and perceived resources provided to those with BPD and high BPD features from social relationships (i.e., functional social connectedness). Studies that examined the role of BPD and BPD features on functional social connectedness found that a BPD diagnosis is predictive of less perceived social connection and support (De Panfilis et al., 2015;Lazarus et al., 2020) compared to individuals without psychopathology. While one study suggests that women with BPD report less closeness to their intimate partners following threatening situations (Miano, Grosselli, et al., 2017), another study found that there is no significant difference in closeness between those with BPD and those without psychopathology (Lazarus et al., 2020). ...
... Second, some research suggests that support groups or other opportunities to interact with others may help individuals with BPD reduce isolation and increase perceived social support, which may be particularly helpful given the robustness of these findings (e.g., De Panfilis et al., 2015;Pucker et al., 2019). Moreover, teaching people with BPD skills to maintain the relationships they have and avoid prematurely terminating them may help to reduce their sense of isolation. ...
Borderline Personality Disorder and Social Connectedness: A Systematic Review
Article
Full-text available
  • May 2024
Borderline personality disorder (BPD) is a debilitating disorder characterized by deficits in social connectedness, which is a multifaceted construct with structural (i.e., the number, diversity, or frequency of social relationships), functional (i.e., the actual or perceived resources relationships provide), and quality (i.e., the positive and negative aspects of social relationships) elements (Holt-Lunstad, 2018). However, the literature is sparse and lacks integration regarding which specific elements of social connectedness are deficient in BPD and why. This systematic review synthesized the literature on the bidirectional relationship of social connectedness and BPD. Electronic searches of three databases (i.e., PsycInfo, PsycArticles, and PubMed) identified 1,962 articles which underwent title and abstract screening and, if potentially eligible, full-text review. Sixty two articles met the eligibility criteria and underwent data extraction and risk of bias assessment. Cross-sectional research supported associations between BPD and problems in structural, functional, and quality social connectedness, with most research underscoring deficits in quality social connectedness. Preliminary longitudinal research suggested that BPD pathology predicts problems across these domains, but little to no research exists testing the reverse direction. Although people with BPD may not have difficulties forming relationships, they exhibit a range of problems within those relationships. BPD may elicit such problems in social connectedness, but it is unclear whether such issues reciprocally exacerbate and elicit BPD, and longitudinal research investigating such directionality is needed.
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... During inclusion, our V group might have ruminated unable to return to a more neutral neural baseline, unlike NV. Alternatively, the V group might have had different social expectations and even felt rejected in the inclusion condition, comparable to some individuals with borderline personality disorder who only feel less negative emotions in an over-inclusionsituation 67 . In our group, this might reflect a distorted self-view of being the victim and perceiving others as violent and rejecting. ...
... Emotion generation may differ between V and NV due to a social bias, as seen in some patient groups during social inclusion 67,74 . Individuals with social anxiety more strongly anticipate exclusion and patients with borderline personality perceive exclusion even when being included. ...
Increased anger and stress and heightened connectivity between IFG and vmPFC in victims during social interaction
Article
Full-text available
  • Apr 2024
Self-identification as a victim of violence may lead to increased negative emotions and stress and thus, may change both structure and function of the underlying neural network(s). In a trans-diagnostic sample of individuals who identified themselves as victims of violence and a matched control group with no prior exposure to violence, we employed a social exclusion paradigm, the Cyberball task, to stimulate the re-experience of stress. Participants were partially excluded in the ball-tossing game without prior knowledge. We analyzed group differences in brain activity and functional connectivity during exclusion versus inclusion in exclusion-related regions. The victim group showed increased anger and stress levels during all conditions. Activation patterns during the task did not differ between groups but an enhanced functional connectivity between the IFG and the right vmPFC distinguished victims from controls during exclusion. This effect was driven by aberrant connectivity in victims during inclusion rather than exclusion, indicating that victimization affects emotional responses and inclusion-related brain connectivity rather than exclusion-related brain activity or connectivity. Victims may respond differently to the social context itself. Enhanced negative emotions and connectivity deviations during social inclusion may depict altered social processing and may thus affect social interactions.
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... Our findings emphasise the relevance of cognitive biases for events with both a negative and a positive valence. This is in line with an increasing awareness that changes in social-cognitive processes in BPD are not restricted to a hypersensitivity for negative events, but also to alterations when evaluating positive events (see for example [70][71]). The differential relevance of the valence of events is also in line with studies showing that attributional processes differ depending on a positive and negative context in their underlying mechanism and consequences for well-being (see for example [72]). ...
Attributional style in Borderline personality disorder is associated with self-esteem and loneliness
Article
Full-text available
  • Aug 2024
Background Attributions are the processes by which individuals explain the causes of positive and negative events. A maladaptive attributional style has been associated with reduced self-esteem, psychosocial functioning, and mental health. Although many psychosocial interventions target an individual’s attributional style in mental disorders, studies of its alterations in Borderline Personality Disorder (BPD) are sparse. This study aimed to investigate the attributional style in patients with BPD in comparison to healthy control individuals (HC) and its association with self-esteem and psychosocial functioning. Methods The participants (32 patients with a diagnosis of BPD, 32 HC, groups were balanced for sex, age and education) assessed their attributional style in regard to locus of control, stability and globality for positive and negative scenarios. Attributional style was compared between groups and linked to self-reports of self-esteem, loneliness and psychosocial functioning in different social domains while controlling for BPD and depressive symptom severity. Results Individuals diagnosed with BPD reported a maladaptive attributional style for both positive and negative events. This was found to be strongly related with lower self-esteem and higher levels of loneliness, but not with psychosocial dysfunctions assessed in different social domains. The severity of BPD and depressive symptoms did not fully explain the association of attributional style with self-esteem and loneliness. In contrast, correcting for acute psychopathology actually strengthened the relationship between self-esteem and maladaptive inferring causality for positive events. Conclusion The differential association of attributional style for positive and negative events with self-esteem and psychosocial functioning highlights the importance of considering the different facets of inferring causality during psychosocial interventions. Our findings suggest that the significance of cognitive alterations may change with remission of acute BPD and depressive psychopathology, depending on the valence of an event.
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A Systematic Review of Existential Concerns in Borderline Personality Disorder
Article
  • Apr 2023
Background Existential philosophy and psychotherapy focuses on the “givens” of human experience, including feelings of meaninglessness, isolation, death anxiety, and concerns surrounding identity and freedom. Although borderline personality disorder (BPD) is arguably characterized by issues in a number of these domains, it has not been systematically examined through the lens of existential therapy. Method The current systematic review included 37 articles which examined existential concerns in relation to BPD. Results These articles highlighted the predominance of chronic identity and isolation-related concerns in BPD, as well as the potential role of meaning in buffering against the distress of BPD, such as suicidality and comorbid depressive features. Implications The implications of existential phenomenological findings in the conceptualization of BPD, treatment and future existential research are discussed.
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A First Look at the Structured Clinical Interview for DSM-IV Personality Disorders Screening Questionnaire: More Than Just a Screener?
Article
Full-text available
  • Oct 2003
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.
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The Ordinal Effects of Ostracism: A Meta-Analysis of 120 Cyberball Studies
Article
Full-text available
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.
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Cyberostracism: Effects of being ignored over the Internet.
Article
  • Nov 2000
  • J PERS SOC PSYCHOL
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.
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Adaptive Disengagement Buffers Self-Esteem From Negative Social Feedback
Article
  • Sep 2014
  • Pers Soc Psychol Bull
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.
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