ArticlePDF Available

Autonomic vulnerability to biased perception of social inclusion in borderline personality disorder


Abstract and Figures

Background Individuals with Borderline Personality Disorder (BPD) feel rejected even when socially included. The pathophysiological mechanisms of this rejection bias are still unknown. Using the Cyberball paradigm, we investigated whether patients with BPD, display altered physiological responses to social inclusion and ostracism, as assessed by changes in Respiratory Sinus Arrhythmia (RSA). Methods The sample comprised 30 patients with BPD, 30 with remitted Major Depressive Disorder (rMDD) and 30 Healthy Controls (HC). Self-report ratings of threats toward one’s fundamental need to belong and RSA reactivity were measured immediately after each Cyberball condition. Results Participants with BPD showed lower RSA at rest than HC. Only patients with BPD, reported higher threats to fundamental needs and exhibited a further decline in RSA after the Inclusion condition. Conclusions Individuals with BPD experience a biased appraisal of social inclusion both at the subjective and physiological level, showing higher feelings of ostracism and a breakdown of autonomic regulation to including social scenarios.
Content may be subject to copyright.
R E S E A R C H A R T I C L E Open Access
Autonomic vulnerability to biased
perception of social inclusion in borderline
personality disorder
Maria Lidia Gerra
, Martina Ardizzi
, Silvia Martorana
, Veronica Leoni
, Paolo Riva
, Emanuele Preti
Barbara Francesca Marta Marino
, Paolo Ossola
, Carlo Marchesi
, Vittorio Gallese
and Chiara De Panfilis
Background: Individuals with Borderline Personality Disorder (BPD) feel rejected even when socially included. The
pathophysiological mechanisms of this rejection bias are still unknown. Using the Cyberball paradigm, we
investigated whether patients with BPD, display altered physiological responses to social inclusion and ostracism, as
assessed by changes in Respiratory Sinus Arrhythmia (RSA).
Methods: The sample comprised 30 patients with BPD, 30 with remitted Major Depressive Disorder (rMDD) and 30
Healthy Controls (HC). Self-report ratings of threats toward ones fundamental need to belong and RSA reactivity
were measured immediately after each Cyberball condition.
Results: Participants with BPD showed lower RSA at rest than HC. Only patients with BPD, reported higher threats
to fundamental needs and exhibited a further decline in RSA after the Inclusion condition.
Conclusions: Individuals with BPD experience a biased appraisal of social inclusion both at the subjective and
physiological level, showing higher feelings of ostracism and a breakdown of autonomic regulation to including
social scenarios.
Keywords: Respiratory sinus arrhythmia, Rejection bias, Cyberball paradigm, Polyvagal theory
Borderline Personality Disorder (BPD) is a severe mental
illness affecting approximately 1% of the general popula-
tion [1]. Social dysfunction represents one of the most
enduring and challenging to treat feature of the disorder,
which is not substantially affected by a symptomatic de-
crease or even remission over time [2]. In BPD, social
impairment is fostered by a unique interpersonal hyper-
sensitivity pattern, encompassing extensive preoccupa-
tion with real or imagined abandonment and rejection,
and related distrustful perceptions of others as bad, mal-
evolent, and excluding [35]. Therefore, clarifying the
potential mechanisms fostering this peculiar way of pro-
cessing interpersonal cues is a primary clinical and re-
search goal in BPD study.
Rejection bias in BPD
Recent studies evaluated BPD patientsresponses to
varying degrees of interpersonal inclusion using Cyber-
ball, a virtual ball-tossing game where participants can
be socially excluded, included, or even over-included by
others [6,7]. Results indicate that patients with BPD do
not merely over-reactto actual social exclusion; rather,
they feel rejected and experience greater rejection-
related negative emotions than controls following object-
ive interpersonal inclusion [810]. Moreover, individuals
with BPD feel disconnected from others even when they
© The Author(s). 2021, corrected publication 2021. Open Access This article is licensed under a Creative Commons Attribution
4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as
long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence,
and indicate if changes were made. The images or other third party material in this article are included in the article's Creative
Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative
Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need
to obtain permission directly from the copyright holder. To view a copy of this licence, visit
licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (
0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence:
Department of Mental Health, AUSL of Parma, Parma, Italy
Full list of author information is available at the end of the article
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation
(2021) 8:28
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
face a condition of extreme interpersonal inclusion [11,
12]. Overall, these findings suggest a misperception of
social participation: patients with BPD show biased pro-
cessing of social inclusion, which makes them perceive
rejection even in interpersonal situations that are object-
ively including.
Autonomic correlates of rejection bias in BPD
To date, most BPD studies focused on subjective (i.e.,
explicit, self-reported) emotional reactions to the Cyber-
ball experiment, while the underlying implicit patho-
physiological mechanisms of this rejection bias are yet to
be fully elucidated.
The Polyvagal Theory [13] provides a theoretical
framework to study the Autonomic Nervous System
(ANS) reactivity to perceived threatening interpersonal
cues. According to such theory, the myelinated vagal
system evolved to support flexible adaptation to environ-
mental stimuli. When the environment is appraised as
safe, at the cardiac level, the vagal brakeincreases the
parasympathethic activity on the hearth, slows down the
heart rate, and inhibits the more primitive ANS systems
(i.e., the sympathetic nervous system and the unmiely-
nated vagus) that promote fight/fly or freeze defense
strategies. Ultimately, this serves to support effective so-
cial engagement behaviors. In this way, prosocial-
affiliative interactions can adaptively emerge and persist
over time in safe contexts.
The dynamic functional impact of the myelinated
vagal fibers on the heart is reflected by the amplitude of
the Respiratory Sinus Arrhythmia (RSA), a naturally oc-
curring rhythm in the cardiac cycle at approximately the
frequency of spontaneous breathing [1416]. Thus,
measurement of the amplitude of RSA provides an as-
sessment of the state of the vagal brake: increased vagal
influence on the heart corresponds to high or increased
RSA. By contrast, in challenging or threatening situa-
tions, the vagal brake is withdrawn, leading to physio-
logical states that support the fight, flight, or freeze
behaviors but inhibiting social engagement behaviors.
This vagal withdrawal is reflected in RSA decreases.
Thus, high RSA at rest and in safe environments and the
appropriate RSA suppression in the face of real environ-
mental risks represent a marker of successful self-
regulation. Notably, this flexible and adaptive increase or
decrease in RSA crucially depends on the environmental
risksaccurate appraisal.
The neural ability to distinguish environmental fea-
tures that are safe, dangerous, or life-threatening is
called neuroception, a process of neural detection of risk
that does not require conscious awareness [13]. When
neuroception is impaired, the ANS fails to distinguish
between safe and dangerous contexts accurately: thus,
the environment may be appraised as dangerous when it
is safe. This leads to a mismatch between the actual risk
of the environment and the neurophysiological state,
resulting in an inability to appropriately inhibit the
defense systems and maintain prosocial behaviors in safe
environments. It is possible to measure such mismatch
by assessing RSA both at rest and during various envir-
onmental challenges: low RSA in the absence of environ-
mental demands or in response to stimuli that are not
threatening would suggest that individuals physiologic-
ally appraise and react to safe environments as if they
were actually unsafe [13].
In this regard, accumulating evidence indicates that
patients with BPD exhibit low cardiac vagal tone at rest
[1721], indicating that they present a constant physio-
logical condition of preparedness to face threats and
danger. In the same vein, having low RSA at rest medi-
ates the association between BPD symptoms and reactive
aggression in a non-clinical population [22], suggesting
that impaired vagal control leads to maladaptive social
behaviors in individuals with BPD features.
Three other studies on BPD examined RSA reactivity,
that is, RSA change in response to various experimental
stimuli, like film clips of varying emotional content [23],
mental arithmetic tasks [18], and standardized film and
idiographic imagery paradigms [17]. Overall, these stud-
ies found that, among participants with BPD, RSA
remained as low as at baseline [17] or even decreased
during the experiment [18,23]. These studies suggest
that engaging in an emotional or cognitive experimental
task induces, among patients with BPD, a physiological
state that promotes defensive behaviors, with phylogen-
etically older fight-or-flightresponse, rather than a vis-
ceral state that supports self-regulation and spontaneous
social engagement behaviors.
To our knowledge, no study yet evaluated RSA reactiv-
ity in response to varying degrees of social inclusion in
BPD. Such inquiry could clarify whether BPD patients
subjectively perceive including social scenarios as if they
were rejecting by reacting to them with a breakdown of
the self-regulation and socialization capacities, rooted in
the myelinated vagal systems activity.
It is also important to examine whether such hypothe-
sized in including situations, associated with vagal with-
drawal, truly represents a BPD-specific alteration, by
comparing BPD with a clinical and medicated control
group, with similar illness duration. In this regard, pa-
tients with Major Depressive Disorder (MDD) have also
been found to exhibit peculiar responses to the Cyber-
ball experiment and altered RSA patterns as compared
with Healthy Controls (HC).
As compared with HC, patients with active MDD (i.e.,
during full-blown depressive episodes) experience a
greater sense of threat to psychological fundamental
needs after social exclusion [2429]. Interestingly,
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 2 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
although one study also found that MDD patients report
greater perception of threat after social inclusion than
HC [30], another study argued that such rejection bias
in including situations among patients with active MDD
was explained by BPD comorbidity [31]. Only one study
evaluated how patients with MDD in the remission
phase (rMDD) react to the Cyberball experiment [32].
However, this study assessed social distress related to
the task as a whole, and not after the inclusion and os-
tracism conditions. Thus, it is not known yet whether
the increased sensitivity to ostracism (and possibly the
rejection bias) showed by MDD patients during an active
depressive episode would persist even in the euthymic
phase, thus representing a trait-based phenomenon ra-
ther than just a state-dependent phenomenon that is ap-
parent only during full-blown episodes.
With respect to RSA findings, patients with active MDD
were found to exhibit low resting RSA and atypical RSA
reactivity to various laboratory stressors. Further, during
the remission phase patients with MDD exhibit low rest-
ing RSA but not altered RSA reactivity to laboratory tasks
[3338]. Thus, low RSA at rest seems to represent a
stable, trait-like feature of MDD, which persists even dur-
ing the euthymic phase, when patients with rMDD may
still exhibit distinctive clinical features, such as sub-
threshold psychopathology [35], peculiar personality styles
[36], or symptomatological scars of previous episodes [37].
Conversely, altered RSA reactivity during active phases of
depression is likely to represent a state-effect of full-blown
depressive psychopathology [34]. However, no study yet
measured RSA reactivity to Cyberball in MDD.
Thus, it is not yet clear whether MDD patients exhibit
peculiar patterns of responses to Cyberball associated
with altered RSA reactivity, which persist at the remis-
sion of depressive episodes.
Therefore, in this study we compared BPD patients,
with no current depressive episode, with rMDD patients
on maintenance treatment, with no BPD comorbidity, to
investigate whether RSA alterations following the Cyber-
ball conditions could represent a stable, trait-like elem-
ent that could distinguish the clinical groups, over and
above the confounding effect of full-blown depressive
symptomatology. Importantly, such comparison also al-
lows for controlling for the potential confounding effect
of sub-threshold depressive symptoms. Patients with
BPD often present with depressive symptoms, although
known to be transient, stress reactive and arising from a
primary diagnosis of BPD [39,40]; in the same vein, pa-
tients with rMDD also may experience inter-episodic de-
pressive psychopathology [35].
The present study
This study investigated whether patients with BPD, com-
pared to HC and patients with rMDD, show an altered
emotional response associated with an altered vagal re-
activity after Cyberball conditions of Social Inclusion
and Ostracism, as well as 10 min after Ostracism (Re-
flective stage). Based on previous research, three main
predictions guided our investigation.
First, we expected to replicate the finding that BPD pa-
tients, compared to healthy and clinical controls, would
report reduced levels of satisfaction of fundamental psy-
chological needs (e.g., the need to belong) even in in-
cluding situation both immediately after Ostracism, as
well as at the Reflective stage. This would confirm a
biased perception of social inclusion at the subjective
(i.e., explicit) level in BPD.
Second, we expected that patients with BPD, com-
pared to healthy and clinical controls, would exhibit re-
duced RSA at rest (i.e., before starting the game),
indicating stable difficulties in social predisposition at
the physiological level. Moreover, we expected that at
the ANS level, patients with BPD would show a further
decrease in RSA after the Cyberball Inclusion condition
than baseline RSA. This would indicate that individuals
with BPD physiologically respond to including social sit-
uations as if they were threatening, with a dysfunctional
withdrawal of the vagal brake that leads to increased
physiological arousal, mobilizing defensive reactions but
impeding successful social engagement.
Finally, we hypothesized that a higher perception of
threat to fundamental psychological needs induced by
the Cyberball task would be associated with higher
physiological arousal as indicated by vagal withdrawal
(i.e., a more substantial decline in RSA).
This study involved 30 patients with BPD, 30 patients
with rMDD, and 30 HC. Patients were recruited at the
psychiatry outpatient services of Parma Local Health
Agency (Parma, Italy) from January 2016 to September
2018. HC, matched for age and gender with patients
with BPD, were recruited through advertisements in
meeting places in the local community.
Inclusion and exclusion criteria
Inclusion criteria were: 1) age 1865 years; 2) native Ital-
ian speaker or proficient in Italian; 3) for the clinical
groups, meeting the diagnostic criteria for rMDD or
BPD, assessed by the Structured Clinical Interview for
DSM-5 disorders, Clinician Version (SCID-5-CV) [41]
and the Structured Clinical Interview for DSM-5 Person-
ality Disorders (SCID-5-PD) [42], respectively; 4) scor-
ing< 7 on the 21-item Hamilton Rating Scale for
Depression (HAM-D) [43] and < 7 in the Hamilton Anx-
iety Rating Scale (HAM-A) [44].
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 3 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Exclusion criteria were: 1) any cardio-respiratory
diseases and treatment that directly affect the ANSs
function (e.g., sympatho-mimetic and para-sympatho-
mimetic drugs, alpha and beta receptors blockers, and
anti-muscarinic drugs); 2) cognitive impairment,
assessed by the Wechsler Adult Intelligence Scale Matrix
Reasoning Subtest [45]; 3) any current diagnoses of
Schizophrenia spectrum and other Psychotic Disorders,
Bipolar Disorders, Anxiety Disorders, Post-Traumatic
Stress Disorder, Somatic Symptom and related Disorders
and Eating Disorders. For the BPD group, both current
and lifetime MDD comorbidity also was an exclusion
criterion. However, for both clinical groups, we included
patients with other previous lifetime disorders, though
fully remitted at the study time (i.e., Adjustment disor-
ders, Substance-related disorders, Eating Disorders,
Obsessive-Compulsive Disorder). Patients were not ex-
cluded for regular psychotropic medication use.
Participants were told that the researchers were in-
vestigating Mental visualization and individual differ-
ences in heart rate and psychological responses.This
cover story is thought to maximize the experiments
ecological validity [46]. Participants gave written in-
formed consent to participation and, after completion
of the experiment, were extensively debriefed and
given detailed information about the study and its
purposes, with the opportunity to have their data de-
leted should they wish so.
The total sample size collected (N= 90) exceeded the
minimum amount required (N= 54) estimated using a
priori sample size calculation, obtained for repeated-
measures analyses of variance (ANOVA) considering
both within and between interactions (1-ß = .95, α= .05,
effect size F = .25). The sample size was computed with
G*power [47] based on the effect size of previous studies
that compared BPD with two other clinical groups [48].
We enlarged the a-priori required sample size up to 30
per group to account for covariates, such as age, Body
Mass Index (BMI), alcohol and tobacco consumption,
known to affect RSA.
Psychometric assessment
All participants completed a general demographic ques-
tionnaire on age, gender, BMI, physical activity, educa-
tional level, occupational and marital status, and
habitual consumption of psychotropic substances (alco-
hol, caffeine, and nicotine).
Psychosocial functioning was assessed with the Global
Assessment of Functioning Scale (GAF) [49].
Experimental procedure
Participants were led into a quiet and soft illuminated
room and were instructed to relax and remain seated
comfortably. At the beginning of the experimental ses-
sion, participants were instructed to sit quietly with their
eyes open, and a 2-min resting baseline electrocardio-
gram (ECG) was recorded to assess RSA at rest.
Subsequently, they participated in a Cyberball experi-
ment and completed different measures of their current
emotional state. ECG recordings were collected over the
entire duration of the experimental session to extract
phasic autonomic measures (i.e., RSA reactivity). Please
refer to Fig. 1for a graphical display of the experimental
Cyberball experiment
Inclusionary status was manipulated using a classic para-
digm called Cyberball (Cyberball (version 4.0) [Software]
available from This
virtual ball-tossing game has been developed to induce
feelings of ostracism in controlled settings [7]. Following
the typical procedure [46], participants were told that in-
vestigators were interested in the effects of mental
visualization on a subsequent task and that a good way
to warm up was to engage in a mental visualization exer-
cise with other online players. In actuality, these two
Fig. 1 Experimental procedure
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 4 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
other players were not real; instead, they were
computer-controlled confederate players, identified
using a name. All participants were enrolled in two con-
secutive conditions of the Cyberball game: initially, they
were included in a belonging game (i.e., receiving the
ball about a third of the time, roughly 33% of the total
throws) and then ostracized (i.e., receiving the ball once
from each computer-controlled player and then never
again, roughly 10% of the total throws). The order of the
Inclusion-Ostracism conditions was kept fixed for all
participants (for a similar procedure, see: [50]).
Manipulation checks
After each Cyberball condition, participants rated the
percentage of throws (0100%) they received during the
game as a manipulation check. They were then asked to
report how excluded (I felt excluded) and ignored (I
felt ignored) they felt during each Cyberball session. Re-
sponses were rated on 10-point scales (ranging from 1 =
not at all to 10 = very much). The two items were com-
bined in an overall index of feelings of being excluded
and ignored. Higher scores indicate greater feelings of
Subjective responses to the Cyberball game
Participants were asked to report their feelings three
times: after Cyberball Inclusion, immediately after
Cyberball Ostracism, and 10 min after completing the
experiment (i.e., Reflective stage).
The Need-Threat Scale (NTS) measures satisfaction
with the four fundamental needs potentially affected
by ostracism in a 12-item scale: the need to have
pleasant interactions with others (belonging), the need
need to influence our social environment (control),
and the need to avoid our fear of death by making an
impact on the world (meaningful existence) [51].
Lower scores reflect the ostracism distress,e.g.a
greater perceptions of threat to these fundamental
needs. In this sample, the internal consistency of NTS
was good across all assessment times (α
= .79;
=.81; α
reflective stage
= .87).
Autonomic responses to the Cyberball game
Patients were fitted with three 10 mm Ag/AgCl pre-
gelled adhesive electrodes for an ECG (ADInstruments,
UK) placed in an Einthovens triangle configuration.
The ECG was sampled at 2 kHz and online filtered
with the Mains Filter. RSA values were extracted for
the entire duration of the baseline-block (120 s), for
the last 120 s of the condition-blocks (Inclusion and
Ostracism) and at Reflective stage (120 s), in line with
guidelines [52].
The peak of the R-wave of the ECG was detected from
each sequential heartbeat. The R-R intervals were ex-
tracted, and the artifacts were edited by integer division
or summation. Editing consisted of visual detection of
outlier points, typically caused by failure to detect an R-
peak (e.g., edit via division) or faulty detections of two or
more peaks within a period representing the R-R interval
(e.g., edit via summation). The amplitude of RSA
[expressed in ln (msec)
], calculated as the natural loga-
rithm of the variance of heart rate activity across the fre-
quency band associated with spontaneous respiration,
was quantified with CMetX [53,54].
Statistical analysis
Descriptive statistics were performed to detail the socio-
demographic and clinical characteristics of the sample.
Cyberball experiment
Manipulation checks
Two 3*2 repeated measure analyses of variance
(ANOVA) with a Group (BPD vs. rMDD vs. HC) by
Condition (Inclusion vs. Ostracism) design were per-
formed, with the post-Cyberball ratings of percentages
of ball tosses received and feelings of being excluded/ig-
nored as dependent variables.
Subjective responses
A 3*3 repeated-measures ANOVA was conducted with
Need-Threat Scale (NTS) scores as the dependent vari-
able to examine how the perceived threats to fundamen-
tal needs were influenced by the clinical status (Group:
BPD vs. rMDD vs. HC) and by the experimental Condi-
tion (Inclusion vs. Ostracism vs. Reflective Stage).
Autonomic responses
Finally, a 3*4 Group (BPD vs. rMDD vs. HC) by Condi-
tion (Baseline vs. Inclusion vs. Ostracism vs. Reflective
Stage) ANCOVA was used to identify whether the pat-
tern of changes in RSA throughout the game varied
among groups. Age, BMI, alcohol and tobacco consump-
tion were considered as covariates because they could
affect RSA and differed among diagnostic groups.
Simple effects analyses were used to evaluate signifi-
cant main and interaction effects. All the analyses were
carried out using SPSS software (IBM SPSS 25.0).
Association between subjective and autonomic responses to
Cyberball conditions
Finally, we performed three linear regression analyses
(enter method) to evaluate whether NTS scores pre-
dicted RSA following Inclusion, Ostracism and at the
Reflective Stage, whilst controlling for confounding vari-
ables. In all the analyses, we entered the covariates
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 5 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
mentioned above - age, BMI, alcohol and tobacco con-
sumption as well as RSA at baseline.
The socio-demographic and clinical characteristics of
the participants are shown in Table 1.
The sample consisted of 90 participants, of which
85.6% were women. This gender distribution reflects the
epidemiology of BPD in clinical treatment population:
although in the general population there is no d iffer-
ence in the prevalence of BPD between males and fe-
males [55], in clinical settings BPD is diagnosed
predominantly in females [49], likely for the greater
proneness of women with BPD to seek outpatient treat-
ment [56]. HC and patients with rMDD were matched
for sex to the BPD sample, resulting in no gender differ-
ences in the three groups. In terms of age, patients with
rMDD were older than both the BPD and HC groups,
and, accordingly, less likely to live alone/with parents or
to be students. They also had a greater BMI and re-
ported to consume alcoholic beverages and tobacco to a
lesser extent than the other groups. These differences
seem to be mostly related to the age difference. As com-
pared to the clinical groups, HC were more likely to
have a college/university level of education and were all
employed, with a greater level of global functioning.
Cyberball experiment
Manipulation checks
As expected, there was a significant effect of the experi-
mental Condition on participantsratings of both per-
ception of percentages of ball throws received (F
431.22, p< .01, η
= .83) and feelings of being ig-
nored and excluded (F
= 184.27, p< .01, η
= .68).
As compared to the Inclusion condition, after Ostracism
participants reported that they received a lower percent-
age of ball tosses (Ostracism 2.58 ± .37 < Inclusion
40.26 ± 1.83), and that they felt more ignored and ex-
cluded (Ostracism 4.34 ± .23 > Inclusion 1.29 ± .08).
These results suggest that the Cyberball manipulation
was successful.
Importantly, this effect held irrespective of the partici-
pantsclinical status, as indicated by the absence of any
significant Group effect (percentage of throws received:
= 1.91, p= .15, η
= .04; feeling of being ig-
nored/excluded: F
= 1.13, p= .33, η
= .03) nor
Group by Condition interaction (percentage of throws
received: F
= 2.06, p= .13, η
= .05; feeling of be-
ing ignored/excluded: F
= .59, p= .55, η
= .01.
Thus, HC and participants with BPD and rMDD were
equally cognitively aware of their inclusionary status
during the game.
Subjective responses to the Cyberball game
Overall, participants reported that their fundamental
needs were more threatened in the Ostracism than in
the Inclusion condition (p< .01, CI = 1.53, 2.14) and
were then restored at the Reflective stage, as compared
with the Ostracism condition (p< .01, CI = -.51, .11)
(main within-subject effect of Condition; Table 2;
Fig. 2A). Perception of threats to fundamental needs also
varied across groups, with a tendency of BPD to report
lower NTS scores (main between-subjects effect of
Group without significant post hoc comparisons; Table
2). However, these main effects were better qualified by
significant Group by Condition interaction (Table 2): pa-
tients with BPD reported lower satisfaction with funda-
mental needs than HC and patients with rMDD in the
Inclusion condition (HC: p< .01, CI = -1.22,-.15; rMDD:
p= .02, CI = -1.13,-.06), but not in the Ostracism condi-
tion (HC: p= 1, CI = -.93,.52; rMDD: p= .62, CI = -
1.10,.35) nor at Reflective stage (HC: p= .13, CI = -
1.26,1.45; rMDD: p= 1, CI = -.81,.77) (effect of Group
within the Group by Condition Interaction for the Inclu-
sion condition: F
= 5.75, η
= .12, p< .01). More-
over, satisfaction with fundamental needs increases from
the Ostracism to the Reflective stage in HC and patients
with rMDD (HC: p< .01, CI = -.86, .16; rMDD: p= .04,
CI = -.70,-.07), but not among patients with BPD (p=1;
CI = -.40, .30) (Effect of Condition within the Group by
Condition interaction for the BPD group: F
= 32.4,
= .43, p< .01) (Fig. 2A).
Autonomic responses to the Cyberball game
Overall, patients with BPD presented a lower vagal
tone as compared to HC (p< .01; CI = -2.22, .63),
but not to rMDD (p= .09; CI = -1.79, 0.85) (main
between-subject effect of Group on RSA levels; Table
2;Fig.2B). Specifically, BPD patients had lower rest-
ing RSA levels than HC (p= .02; CI = .14, 1.90), but
did not differ from rMDD at baseline (p=.81; CI=-
.57, 1.52; Effect of Group within a Group by Condi-
tion interaction for baseline RSA F
=4.43, η
.10, p=.02; Table 2). However, patients with BPD
showed a generally lower RSA than both HC and pa-
tients with rMDD across all the experimental condi-
tions (vs HC, all p
< .001; vs rMDD: Inclusion p=
.086; Ostracism p= .04, Reflective stage p= .05). Fur-
thermore, only in the BPD group RSA levels de-
creased during the experiment (Effect of Condition
within the Group by Condition interaction for the
BPD group: F
= 4.26, η
= .14, p<.01), while
they did not vary in HC nor rMDD patients (respect-
ively, F
=1.76, η
= .06, p=.16 and F
= 1.09,
= .04, p= .36). In particular, patients with BPD
exhibited a marked reduction in RSA from Baseline
to Inclusion (p= .01; CI = .08, 1.01); then, their RSA
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 6 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Table 1 Socio-demographic, clinical and psychometric characteristics
BPD HC rMMD Between-groups differences
n=30 n=30 n= 30 Main effect of factor Group* Post-hoc comparisons
Physiological variables
Age 33.2 ± 12.07 38.9 ± 14.65 49.27 ± 9.96 F
= 12.98, p < .01; ή
= .23 rMDD>BPD, HC (p
< .01)
Sex (F) 27 (90%) 24 (80%) 26 (86.7%) χ
(2) = 1.26, p= .53
Sport 12 (40%) 17 (56.7%) 11 (36.7%) χ
(4) = 4.57, p = .33
BMI 21.77 ± 3.75 22.70 ± 3.40 26.31 ± 6.25 F
= 7.98, p = .01; ή
= .15 rMDD>BPD, HC (p
< .01)
Psychotropic drugs consumption
Alcohol 17 (56.7%) 21 (70%) 7 (23.3%) χ
(2) = 13.87, p = .01
Caffeine 24 (80%) 26 (86.7%) 19 (63.3%) χ
(2) = 4.84, p = .09
Tobacco 26 (86.7%) 8 (26.7%) 5 (16.7%) χ
(2) = 35.02, p < .01
Social variables
Education (yrs) 11.53 ± 2.89 14.76 ± 3.54 11.23 ± 3.35 F
= 10.77, p < .01; ή
= .20 HC> BPD, rMDD (p
< .01)
Family status
Married/living together 7 (23.3%) 16 (53.3%) 20 (66.6%) χ
(6) = 16.29, p = .01
Separated/divorced 6 (20%) 1 (3.3%) 4 (13.4%)
Widowed 0 (0%) 1 (3.3%) 1 (3.3%)
Living alone/with parents 17 (56.7%) 12 (40%) 5 (16.7%)
Employed 16 (53.3%) 17 (53.4%) 22 (73.3%) χ
(6) = 29.13, p = .01
Housewife 0 (0%) 4 (13.3%) 6 (20%)
Students 6 (20%) 10 (33.3%) 0 (0%)
Unemployed 8 (26.7%) 0 (0%) 2 (6.7%)
Clinical and psychometric variables
DSM-5 Comorbidity
Adjustment disorder 12 (40%) ––
Substance Use disorders (in full remission) 10 (33.3%) ––
Alcohol Use disorders (in full remission) 3 (10%) ––
Obsessive Compulsive Disorder ––1 (3.3%)
Eating disorders 2 (6.7%) ––
Personality disorders 11 (36.7%) 3 (10%)
Passive-aggressive 2 (6.7%) ––
Paranoid 1 (3.3%) ––
Histrionic 2 (6.7%) ––
Narcissistic 6 (20%) ––
Dependent 1 (3.3%) ––
Obsessive-Compulsive ––3 (10%)
Mood stabilizers 25 (83.3%) 4 (13.3%) χ
(1) = 28.5, p < .01
Antidepressants 13 (43.3%) 30 (100%) χ
(1) = 24.7, p < .01
Antipsychotics 22 (73.3%) 4 (13.3%) χ
(1) = 21.08, p< .01
Benzodiazepines 21 (70%) 14 (46.7%) χ
(1) = 4.05, p = .04
Duration of illness 15.20 ± 12.1 11.77 ± 8.77 F
= 1.59, p= .21; ή
= .03
Matrix reasoning 16.80 ± 2.42 20.10 ± 2.94 18.17 ± 3.38 F
= 9.52, p < .01; ή
= .18 HC > BPD, rMD D (p
< .04)
GAF 72.07 ± 7.31 96.6 ± 4.76 86.57 ± 6.39 F
= 117.11, p < .01; ή
= .73 HC > rMDD>BPD (p
< .01)
*F-Tests in One-way ANOVA have been performed to compare continuous variables; Chi square tests (χ2) have been performed to compare categorical variables.
BPD = patients with Borderline Personality Disorder; HC = Healthy Controls; rMDD = patients with Major Depressive Disorder in remission; BMI = Body Mass Index;
GAF = Global Assessment of Functioning
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 7 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
levels did not vary and remained low moving from
the Inclusion to the Ostracism condition (p=1, CI=-
.51, .31) and from Ostracism to the Reflective stage
(p= 1, CI = -.62, .22) (Fig. 2B).
Association between subjective and autonomic responses to
Cyberball condition
Having found that participants with BPD, as compared
with non-BPD controls, reported greater threats to their
fundamental needs as well as a marked decrease in RSA
after the Cyberball Inclusion condition, we next
evaluated whether the subjective perception of threat in
the overall sample was associated with a breakdown of
vagal control at the physiological level. NTS scores pre-
dicted RSA levels only in the Inclusion condition (b=
.22, p= .04), but not after Ostracism (b= .08, p= .48) nor
at the Reflective stage (b= .04, p= .69). This held true
even after controlling, as above, for age, BMI, alcohol
and tobacco consumption and also for the baseline levels
of RSA (Inclusion: b= .11, p= .05; Ostracism: b=.05,
p= .32; Reflective stage: b= .05, p= .41), indicating that
higher perception of threats to fundamental needs after
Table 2 Effect of Experimental Condition, Group Status and Their Interactions on NTS scores and RSA levels
Variables BPD HC rMDD Condition Group Interactions Condition X Group
NTS scores F
= 121.34
= .74
p< .01
= 3.41
= .07
p= .04
= 3.24
= .07
p= .04
Inclusion 4.57 ± .15 5.26 ± .15 5.16 ± .15
Ostracism 2.95 ± .21 3.15 ± .21 3.33 ± .21
Reflective stage 3.00 ± .23 3.66 ± .23 3.69 ± .23
RSA levels F
= .29
= .01
p= .84
= 9.87
= .19
p< .01
= 3.44
= .01
p= .02
Baseline 4.52 ± .27 5.54 ± .22 4.99 ± .26
Inclusion 3.98 ± .27 5.56 ± .22 4.94 ± .26
Ostracism 4.07 ± .26 5.61 ± .21 5.12 ± .25
Reflective stage 4.28 ± .24 5.83 ± .20 5.21 ± .23
BPD = patients with Borderline Personality Disorder; HC = Healthy Controls; rMDD = patients with Major Depressive Disorder in remission; NTS = Need Threat Scale;
RSA = Respiratory Sinus Arrhythmi a
Fig. 2 NTS scores (Panel A) and RSA levels (Panel B) across test conditions. Note: NTS = Need Threat Scale (higher scores represent greater
satisfaction with basic needs); RSA = Respiratory Sinus Arrhythmia. Error bars depict standard error. * = p< .05. In Panel A the satisfaction with basic
need (NTS, Y axis) across conditions (Inclusion, Ostracism and Reflective stage, X axis) in the three groups. After the Inclusion condition, BPD
patients experienced lesser satisfaction with basic needs than HC and rMDD. Furthermore, their level of satisfaction with basic needs did not
improve moving from the ostracism condition to the reflective stage. In Panel B Respiratory Sinus Arrhythmia (RSA, Y axis) across conditions
(Baseline, Inclusion, Ostracism and Reflective stage, X axis) in the three groups. RSA decreased from Baseline to Inclusion in BPD patients, but did
not vary in HC nor rMDD patients across the experimental conditions
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 8 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
being included by others parallels a less efficient vagal
control during including social interactions. Notably, we
did not control this association for multiple
The present study investigated whether BPDs biased
perception of social interactions is associated with re-
duced physiological regulation, as indexed by impaired
vagal control, in response to experimental conditions of
social Inclusion and Ostracism. Three main findings
Firstly, during the Cyberball task, individuals with
BPD subjectively reacted to inclusion with a higher per-
ception of threat to fundamental needs than healthy and
clinical controls. Furthermore, while in non-BPD con-
trols the fundamental needs were restored at the Reflect-
ive stage, patients with BPD did not show such recovery
from ostracism. Secondly, patients with BPD presented
lower resting RSA than HC, indicating stable difficulties
in social predisposition. Moreover, only in patients with
BPD, RSA further decreased in the inclusion condition
and remained low during Ostracism and the Reflective
stage. Finally, greater subjective perception of threats to
fundamental needs in the Inclusion condition was asso-
ciated with decreased RSA after being included, indicat-
ing that, during the Cyberball experiment, subjective
and physiological measures of perceived threats after be-
ing included paralleled each other.
At the subjective level, after being ostracized, as ex-
pected, all participants reported being threatened in
their fundamental needs [6]. However, only in the Inclu-
sion condition patients with BPD reported a weaker
sense of belongingness than did HC and patients with
rMDD. This indicates that patients with BPD do not
over-react to actual rejection, which is subjectively
threatening for everybody; instead, they emotionally
react to including interpersonal situations as they were
threatening. Although patients with BPD appeared cog-
nitively aware of the different degrees of threat conveyed
by Inclusion and Ostracism and correctly estimated the
percentage of ball tosses received during each condition,
they subjectively perceived a higher level of danger in
the including and accepting interaction than non-BPD
participants. This is in line with previous Cyberball stud-
ies showing that patients with BPD during the Inclusion
condition experienced a greater sense of exclusion and a
lesser sense of inclusion and belonging [811,57] and
reported lower feelings of social connection and greater
threats to their social needs than controls even when
over-included by others [11,12]. Thus, patients with
BPD show a biased subjective experience of social inclu-
sion during Cyberball [8,57].
Furthermore, in line with the Temporal Need-
Threat Model of ostracism [51], in this study,
threatened needs quickly recovered a few minutes
after Ostracism among both HC and rMDD. While
the detection of ostracism immediately generates
negative emotions, this in turn quickly motivates indi-
viduals to regulate their initial social pain in order to
access more positive emotions and restore functional
relations with others after Ostracism is over. Con-
versely, in this study patients with BPD did not re-
cover from Ostracism; rather, they kept reporting
feeling threatened in their need to belong. The ability
to recover faster and in more functional ways from
social exclusion has been found in individuals with
higher psychological flexibility levels. By contrast, a
delayed emotional recovery suggests difficulties in ac-
cess to, and use of, a wider range of emotion regula-
tion strategies to cope with ostracism experiences [58,
59]. For instance, socially anxious individuals exhibit
a slow recovery from the negative feelings induced by
ostracism [60].
This study also demonstrated that these explicit,
subjective findings parallel a corresponding pattern of
change in ANS reactivity at the implicit, physiological
level. BPD patients exhibited a lower RSA at baseline
than HC. Moreover, they also uniquely showed a fur-
ther decrease in RSA after the Cyberball Inclusion
condition when they also reported, at the subjective
level, to be threatened (more than non-BPD controls)
in their need to belong.
Concerning baseline RSA, the present findings
confirm that patients with BPD show lower vagal
control at rest than HC [1721]. This indicates that
even in the absence of interpersonal challenges (i.e.,
even before the Cyberball experiment), the BPD
group exhibits a physiological state of preparedness
for defensive rather than prosocial behaviors. Not-
ably, the finding of low RSA at rest in clinical popu-
lations, as compared to HC, is not limited to BPD
but also characterizes patients with anxiety disor-
ders, conduct disorders, autism spectrum disorders,
depression and schizophrenia (see for a review [61])
and, in this study, also patients with MDD in remis-
sion. This is not surprising given that patients with
diverse psychiatric disorders exhibit various degrees
of social dysfunction that are likely to be paralleled,
at the ANS level, by the inhibition of the social en-
gagement system when the vagal brake is removed.
This study extends these findings by indicating that
even after clinical remission patients with MDD
maintain a state of physiological arousal predispos-
ing to defensive rather than prosocial behaviors;
consistently, they also showed lower psychosocial
functioning than HC, as indexed by lower GAF
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 9 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
scores, possibly as a scar effectof previous epi-
sodes. Thus, low RSA at rest, rather than being
disorder-specific, could represent a marker of the
difficulties in social behaviors shared by several psy-
chiatric disorders.
However, among HC and patients with rMDD, RSA
levels did not change from baseline across the three
Cyberball experimental conditions. This indicates that
they correctly appraised, at the physiological level, that
the task conveyed only minimal interpersonal stress
(Cyberball lasted about two minutes and involved two
unknown avatars online), but not greater threatening
risks. Thus, the experimental Cyberball conditions
employed in this study ultimately favored, among HC
and patients with rMDD, the maintenance of their vagal
regulation on the heart during and after the experiment.
Therefore, while at the subjective level both HC and pa-
tients with rMDD accurately perceived the Ostracism
condition as threatening their need to belong, they
maintained their capacity to regulate the vagal control
and then quickly recovered from their negative affective
states at the Reflective stage. On the contrary, patients
with BPD experienced a further drop in RSA after the
benign experimental condition of Inclusion. This vagal
withdrawal then persisted even at the reflective stage.
Thus, patients with BPD are not only biased to subject-
ively perceive rejection even in including contexts, or
when ostracism is over: they also implicitly appraise, at
the physiological level, such benign conditions as signal-
ing threats in the environment. This altered neurocep-
tion [13] of favorable social environments, in turn, leads
BPD patients to regulate their ANS to a state that would
support fight and flight responses but impedes social
flexibility and prosociality even after including interper-
sonal exchanges or when social interactions are over.
These findings are in keeping with other studies investi-
gating the potential neurophysiological bases of BPD
biased perception of rejection. For instance, during the
Cyberball Inclusion condition, patients with BPD show
an enhanced P3b event-related potential, which usually
signals social rejection [12,62] and hyper-activate the
social painneural circuitry (i.e., the dorsal anterior cin-
gulate cortex and the dorsomedial prefrontal cortex)
[10]. These data suggest that patients with BPD process
objectively positive social interactions by activating
physiological and neural responses that signal rejection
and threat.
Finally, in this study, the subjective appraisal of threats
to ones need to belong after the Inclusion condition
(NTS scores) directly correlated with the physiological
appraisal of the Inclusion condition as unsafe (decreased
RSA ratings after Inclusion), but not in any other stage
of the Cyberball task. This indicates that the tendency to
subjectively perceive including interpersonal interactions
as if they were excluding is underlined by a correspond-
ing altered physiological appraisal of such safe context
as if it was unsafe and risky. Such altered appraisal inev-
itably leads to the inappropriate activation of the ANS
defensive systems in an environment that is actually safe
and inhibits the prosocial responses fostered by the mye-
linated vagal regulation, which though would be re-
quired and adaptive in safe contexts [13].
Overall, these results point out to a lowered ostracism
detection thresholdin BPD: when the threshold for de-
tecting signals of ostracism in the environment is set too
low, the ostracism detection system registers a high pro-
portion of false positives, interpreting benign (or even
mildly favorable) interpersonal events as potential
threats to acceptance [63]. Such interpretation is sup-
ported by converging lines of evidence indicating that
patients with BPD systematically underestimate positive
feedback from others. For instance, they show lesser ex-
pectations of being socially accepted than controls and
cannot adjust these expectations even after receiving ac-
tual positive feedback [64]. Furthermore, in behavioural
economics games, BPD under-notice othersfair behav-
iour toward them and react to that as if it was unfair by
punishing them [65]. Moreover, after experiencing actual
social acceptance, they behave less cooperatively toward
others [64]. Finally, individuals with BPD respond with
less positive emotions than controls to othersfriendly
behaviour [66], and under-notice trust in others [6769].
These findings are also consistent with clinical obser-
vations that patients with BPD do not seem to benefit
from benign, fairand accepting attitudes of others to-
ward them to regulate their emotional states, nor from
neutral interpersonal conditions where interpersonal re-
jection, although experienced in the past, is no longer
occurring. According to object-relations theory [70,71],
this response pattern may reflect the patients uncon-
scious idealized need of finding a perfectly accepting
relationship with others. However, this intense need is
unlikely to be fulfilled in reality, since human interac-
tions may also exhibit transient difficulties or ruptures
that are usually overcome by repairing trust and main-
taining reciprocity. For patients with BPD, though, such
less-than-perfect interpersonal interactions may not be
enough to fulfill their unconscious idealized need for
interpersonal belonging. Thus, in the desperate attempt
to protect this unconscious hope of a perfectrelation-
ship, individuals with BPD need to project ones negative
affect into the others; this makes them perceive includ-
ing social interactions as if they were unfair and exclud-
ing. This threatens the possibility to feel safe and
connected during realinterpersonal exchanges.
Such dynamics could have significant implications for
treatment. Patients with BPD could feel easily threat-
ened, hurt and ignored even in the context of
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 10 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
therapeutic relationships, and may find it difficult to ap-
praise them as trustworthy, regardless of the objectively
cooperative stance of the therapist. This may affect the
therapeutic alliance and possibly evoke negative counter-
transference reactions in the clinicians, such as feelings
of frustration, inadequacy, and hopelessness. It is hence
important, for the clinician, to recognize that these feel-
ings in fact correspond to some aspects of their patients
inner experience that they cannot tolerate. By maintain-
ing this empathic focus, the therapist can then explore
with the patients their perception to be threatened dur-
ing treatment and help them to appreciate that, although
the therapeutic relationship cannot provide a perfect or
magical solution to their problems, it can nonetheless
represent something of value to them. In the same vein,
the clinicians may encourage BPD patients to recognize
positive aspects in their real-life interpersonal relation-
ships by clarifying the defensive distortion of benign
interpersonal encounters as threatening. In turn, this will
favor the development of more gratifying and satisfac-
tory interpersonal relationships [72].
The results of this study should be interpreted in light
of some limitations.
First, our patients with BPD and rMDD exhibited
some socio-demographical differences, above all age.
This reflects the epidemiological distribution of BPD
and MDD. While BPD has an onset in adolescence or
early adulthood, and most patients experience symp-
tomatic remission in a few decades [73], MDD can
develop at any age, with a median age at onset at
3040 years [74].
Moreover, we could not rule out the role of
pharmacotherapy on RSA levels, since both the clin-
ical groups kept their usual medication regimen, in
compliance with the Local Ethical Authority require-
ments and good clinical practice. Nonetheless, in this
study, patients with (N= 43) and without (N=17) an-
tidepressants did not differ in baseline RSA (F
.38, p=.54, η2
= .01), regardless of their clinical
group status. Moreover, in our analyses, we controlled
for other physiological variables that have previously
been demonstrated to affect RSA (i.e., age, BMI, alco-
hol and tobacco consumption) [7578].
Furthermore, while in the present study healthy and
clinical controls subjectively perceived the ostracism
condition as potentially threatening (thereby confirming
the widely-replicated validity of the Cyberball experi-
mental manipulation), at the physiological level they did
not exhibit a parallel withdrawal in RSA. This is likely
due to the successful recruitment of self-regulatory abil-
ities in HC and in patients with rMDD, which favored
the appraisal, at the physiological level, of the Cyberball
ostracism condition as a minimal and transient interper-
sonal stress, and therefore the maintenance of vagal
control. This was not the case for patients with BPD,
who are known to react with increasing distress to any
situation where rejection is a possibility (in the present
study, to the Cyberball social inclusion condition) be-
cause of their self-regulation difficulties [79,80]. A sub-
sequent vagal suppression did not occur from inclusion
to ostracism, among patients with BPD, because it was
already withdrawn from baseline to inclusion, and RSA
reactivity scores could be susceptible to a floor effect of
functional adaptations [81].
Finally, in our study, we interpreted RSA in the Poly-
vagal Theory framework, which posits that RSA suppres-
sion is associated with the neurophysiological appraisal
of the environment as dangerous, thus leading to defen-
sive, rather than pro-social behaviors. However, contra-
dictory findings have been reported regarding RSA
changes in response to varying environmental cues [82]
and some researchers suggested that the evolution of the
parasympathetic ANS has a greater anatomical and
physiological complexity than what was proposed by the
Polyvagal Theory [16,83]. Therefore, the specificity of
RSA as a physiological marker of BPD patientsbiased
perception of social participation needs to be confirmed
by further research.
The results of this study indicate that patients with BPD
perceive (at the subjective level) threats to their need to
belong during accepting social encounters, as well as
when the experience of ostracism is no longer present.
They also appraise (at the implicit, physiological level)
such circumstances as threatening and dangerous,
thereby showing an autonomic response characterized
by increased physiological arousal and proneness to de-
fensive reactions and breakdown in prosocial behavior.
These findings support the view that patients with BPD
appraise and react, both subjectively and physiologically,
to positive social contexts as if they were unsafe and
rejecting. This prevents them from appreciating and re-
ciprocating objectively inclusive, fairsocial exchanges.
Thus, individuals with BPD may benefit from interven-
tions that help them to accurately appraise positive cues
in their social and interpersonal interactions.
ANOVA: analyses of variance; ANS: Autonomic Nervous System; BMI: Body
Mass Index; BPD: Borderline Personality Disorder; ECG: Electrocardiogram;
GAF: Global Assessment of Functioning; HAM-A: Hamilton Anxiety Rating
Scale; HAM-D: Hamilton Rating Scale for Depression; HC: Healthy Controls;
NTS: Need-Threat Scale; rMDD: remitted Major Depressive Disorder;
RSA: Respiratory Sinus Arrhythmia; SCID-5-PD: Structured Clinical Interview for
DSM-5 Personality Disorders; SCID5-CV: Structured Clinical Interview for DSM-
5 disorders, Clinician Version
Not applicable.
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 11 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Authors MLG, MA, PR, EP, BM, CDP, and VG designed the study. Authors
MLG, MA, SM, VL, PR; EP and CDP managed the literature searches. Authors
MLG, SM and VL recruited the participants. Authors MLG, MA, SM and PO
undertook the statistical analysis. Authors MLG, MA and CDP wrote the first
draft of the manuscript. MLG, MA, SM, VL, CDP, PR, EP, PO, CM and VG
interpreted the results. All authors contributed to and have approved the
final manuscript.
This work was supported by Paola Chiesi and by a PRIN grant on Perception,
Performativity and the Cognitive Sciences to VG.
Availability of data and materials
The dataset analyzed during the current study is available from the
corresponding author on reasonable request.
Ethics approval and consent to participate
Participants gave written informed consent to participation and, after
completion of the experiment, were extensively debriefed and given
detailed information about the study and its purposes, with the opportunity
to have their data deleted should they wish so. Participants were not
reimbursed for their participation. The Local Ethical Authority (Comitato Etico
Unico per Parma, protocol #6266 01/29/2016) approved the study protocol.
All procedures contributing to this work comply with the relevant national
and international committeesethical standards on human experimentation
and with the Helsinki Declaration of 1972, as revised in 2013.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
Department of Mental Health, AUSL of Parma, Parma, Italy.
Department of
Medicine and Surgery, University of Parma, Parma, Italy.
Department of
Psychology, University of Milano-Bicocca, Milan, Italy.
Received: 15 August 2021 Accepted: 20 October 2021
1. Lenzenweger MF. Current status of the scientific study of the personality
disorders: an overview of epidemiological, longitudinal, experimental
psychopathology, and neurobehavioral perspectives. J Am Psychoanal
Assoc. 2010;58(4):74178
2. Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM, et al.
Ten-year course of borderline personality disorder: psychopathology and
function from the collaborative longitudinal personality disorders study.
Arch Gen Psychiatry. 2011;68(8):82737. https://doi:10.1001/archgenpsychia
3. Gunderson JG. Revising the borderline diagnosis for DSM-V: an alternative
proposal. J Personal Disord. 2010;24(6):694708.
4. Clarkin JF, Yeomans FE, Kernberg OF. Psychotherapy for borderline
personality disorder: focusing on object relations. Washington, DC:
American Psychiatric Press; 2006.
5. Poggi A, Richetin J, Preti E. Trust and rejection sensitivity in personality
disorders. Curr Psychiatry Rep. 2019;21(8):19
6. Williams KD, Jarvis B. Cyberball: a program for use in research on
interpersonal ostracism and acceptance. Behav Res Methods. 2006;38(1):
7. Hartgerink CH, Van Beest I, Wicherts JM, Williams KD. The ordinal effects of
ostracism: a meta-analysis of 120 Cyberball studies. PLoS One. 2015;10(5):
8. Staebler K, Renneberg B, Stopsack M, Fiedler P, Weiler M, Roepke S. Facial
emotional expression in reaction to social exclusion in borderline
personality disorder. Psychol Med. 2011;41(9):192938. https://doi:10.1017/
9. Renneberg B, Herm K, Hahn A, Staebler K, Lammers CH, Roepke S.
Perception of social participation in borderline personality disorder. Clin
Psychol Psychother. 2012;19(6):47380.
10. Domsalla M, Koppe G, Niedtfeld I, Vollstädt-Klein S, Schmahl C, Bohus M,
et al. Cerebral processing of social rejection in patients with borderline
personality disorder. Soc Cogn Affect Neurosci. 2013;9(11):178997. https://
11. De Panfilis C, Riva P, Preti E, Cabrino C, Marchesi C. When social inclusion is
not enough: implicit expectations of extreme inclusion in borderline
personality disorder. Pers Disord Theory Res Treat. 2015;6(4):301. https://doi.
12. Weinbrecht A, Niedeggen M, Roepke S, Renneberg B. Feeling excluded no
matter what? Bias in the processing of social participation in borderline
personality disorder. NeuroImage: Clin. 2018;19:34350
13. Porges SW. The polyvagal perspective. Biol Psychol. 2007;74(2):11643.
14. Berntson GG, Cacioppo JT, Quigley KS. Respiratory sinus arrhythmia:
autonomic origins, physiological mechanisms, and psychophysiological
implications. Psychophysiology. 1993;30(2):18396.
15. Porges SW. Orienting in a defensive world: mammalian modifications of our
evolutionary heritage. A polyvagal theory. Psychophysiology. 1995;32(4):
16. Grossman P, Taylor EW. Toward understanding respiratory sinus
arrhythmia: relations to cardiac vagal tone, evolution and biobehavioral
functions. Biol Psychol. 2007;74(2):26385.
17. Kuo JR, Linehan MM. Disentangling emotion processes in borderline
personality disorder: physiological and self-reported assessment of
biological vulnerability, baseline intensity, and reactivity to emotionally
evocative stimuli. J Abnorm Psychol. 2009;118(3):531.
18. Weinberg A, Klonsky ED, Hajcak G. Autonomic impairment in borderline
personality disorder: a laboratory investigation. Brain Cogn. 2009;71(3):279
19. Kuo JR, Fitzpatrick S, Metcalfe RK, McMain S. A multi-method laboratory
investigation of emotional reactivity and emotion regulation abilities in
borderline personality disorder. J Behav Ther Exp Psychiatry. 2016;50:5260
20. Koenig J, Kemp AH, Feeling NR, Thayer JF, Kaess M. Resting state vagal tone
in borderline personality disorder: a meta-analysis. Prog Neuro-
Psychopharmacol Biol Psychiatry. 2016;64:1826
21. Bortolla R, Roder E, Ramella P, Fossati A, Maffei C. Emotional responsiveness
in borderline personality disorder: the role of basal hyperarousal and self-
reported emotional regulation. J Nerv Ment Dis. 2019;207(3):17583. https://
22. Thomson ND, Beauchaine TP. Respiratory sinus arrhythmia mediates links
between borderline personality disorder symptoms and both aggressive
and violent behavior. J Personal Disord. 2019;33(4):54459
23. Austin MA, Riniolo TC, Porges SW. Borderline personality disorder and
emotion regulation: insights from the polyvagal theory. Brain Cogn. 2007;
24. Beeney JE, Levy KN, Gatzke-Kopp LM, Hallquist MN. EEG asymmetry in
borderline personality disorder and depression following rejection. Pers
Disord: Theory Res Treat. 2014;5(2):178.
25. Jobst A, Sabass L, Palagyi A, Bauriedl-Schmidt C, Mauer MC, Sarubin N, et al.
Effects of social exclusion on emotions and oxytocin and cortisol levels in
patients with chronic depression. J Psychiatr Res. 2015;60:1707https://doi.
26. Hsu DT, Sanford BJ, Meyers KK, Love TM, Hazlett KE, Walker SJ, et al. It still
hurts: altered endogenous opioid activity in the brain during social rejection
and acceptance in major depressive disorder. Mol Psychiatry. 2015;20(2):
27. Ernst M, Mohr HM, Schött M, Rickmeyer C, Fischmann T, Leuzinger-Bohleber
M, et al. The effects of social exclusion on response inhibition in borderline
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 12 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
personality disorder and major depression. Psychiatry Res. 2018;262:3339
28. Groschwitz RC, Plener PL, Groen G, Bonenberger M, Abler B. Differential
neural processing of social exclusion in adolescents with non-suicidal self-
injury: an fMRI study. Psychiatry Res Neuroimaging. 2016;255:439https://
29. Reinhard MA, Dewald-Kaufmann J, Wuestenberg T, Musil R, Barton BB, Jobst
A, et al. The vicious circle of social exclusion and psychopathology: a
systematic review of experimental ostracism research in psychiatric
disorders. Eur Arch Psychiatry Clin Neurosci. 2020;270(5):52132 https://doi.
30. Zhang Q, Li X, Wang K, Zhou X, Dong Y, Zhang L, et al. Dull to social
acceptance rather than sensitivity to social ostracism in interpersonal
interaction for depression: behavioral and electrophysiological evidence
from Cyberball tasks. Front Hum Neurosci. 2017;11:162
31. Malejko K, Neff D, Brown R, Plener PL, Bonenberger M, Abler B, et al. Neural
correlates of social inclusion in borderline personality disorder. Front
Psychiatry. 2018;9:653
32. Olié E, Jollant F, Deverdun J, de Champfleur NM, Cyprien F, Le Bars E, et al.
The experience of social exclusion in women with a history of suicidal acts:
a neuroimaging study. Sci Rep. 2017;7(1):18
33. Carvalho Fernando S, Beblo T, Schlosser N, Terfehr K, Otte C, Löwe B, et al.
The impact of self-reported childhood trauma on emotion regulation in
borderline personality disorder and major depression. J Trauma Dissociatio.
34. Bylsma LM, Salomon K, Taylor-Clift A, Morris BH, Rottenberg J. RSA reactivity
in current and remitted major depressive disorder. Psychosom Med. 2014;
35. Judd LL, Akiskal HS, Maser JD, Zeller PJ, Endicott J, Coryell W, et al. A
prospective 12-year study of subsyndromal and syndromal depressive
symptoms in unipolar major depressive disorders. Arch Gen Psychiatry.
36. Kendler KS, Gatz M, Gardner CO, Pedersen NL. Personality and major
depression: a Swedish longitudinal, population-based twin study. Arch Gen
Psychiatry. 2006;63(10):111320.
37. Shea MT, Leon AC, Mueller TI, Solomon DA, Warshaw MG, Keller MB. Does
major depression result in lasting personality change? Am J Psychiatr. 1996;
38. Hamilton JL, Alloy LB. Atypical reactivity of heart rate variability to stress and
depression across development: systematic review of the literature and
directions for future research. Clin Psychol Rev. 2016;50:6779 https://doi.
39. Gunderson JG, Morey LC, Stout RL, Skodol AE, Shea MT, McGlashan TH,
et al. Major depressive disorder and borderline personality disorder revisited:
longitudinal interactions. J Clin Psychiatry. 2004;65(8):104956. https://doi.
40. Goodman M, New AS, Triebwasser J, Collins KA, Siever L. Phenotype,
endophenotype, and genotype comparisons between borderline
personality disorder and major depressive disorder. J Personal Disord. 2010;
41. First MB, Williams JB, Karg RS, Spitzer RL. Structured clinical interview for
DSM-5 disorders: SCID-5-CV clinician version. Arlington, VA: American
Psychiatric Association Press; 2016.
42. First MB, Williams JB, Benjamin LS, Spitzer RL. Structured clinical interview
for DSM-5® personality disorders (SCID-5-PD): with the structured clinical
interview for DSM-5® screening personality questionnaire (SCID-5-SPQ).
Arlington, VA: American Psychiatric Association Press; 2016.
43. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry.
44. Hamilton M. The assessment of anxiety states by rating. Br J Health Psychol.
45. Wechsler D. Wechsler intelligence scale for children. 5th ed. San Antonio,
TX: NCS Pearson; 2014.
46. Williams KD, Cheung CK, Choi W. Cyberostracism: effects of being ignored
over the internet. J Pers Soc Psychol. 2000;79(5):748.
47. Faul F, Erdfelder E, Lang AG, Buchner A. G* power 3: a flexible statistical
power analysis program for the social, behavioral, and biomedical sciences.
Behav Res Methods. 2007;39(2):17591
48. Seidl E, Padberg F, Bauriedl-Schmidt C, Albert A, Daltrozzo T, Hall J, et al.
Response to ostracism in patients with chronic depression, episodic
depression and borderline personality disorder a study using Cyberball. J
Affect Disord. 2020;260:25462
49. American Psychiatric Association. Diagnostic and statistical manual of
mental disorders. 5th ed. Arlington, VA: American Psychiatric Association
Press; 2013.
50. Eisenberger NI, Lieberman MD, Williams KD. Does rejection hurt? An fMRI
study of social exclusion. Science. 2003;302(5643):2902.
51. Williams KD. Ostracism: a temporal need-threat model. Adv Exp Soc Psychol.
52. Berntson GG, Thomas Bigger Jr J, Eckberg DL, Grossman P, Kaufmann PG,
Malik M. Heart rate variability: origins, methods, and interpretive caveats.
Psychophysiology. 1997;34(6):62348
53. Allen JJ, Chambers AS, Towers DN. The many metrics of cardiac
chronotropy: a pragmatic primer and a brief comparison of metrics. Biol
Psychol. 2007;74(2):24362.
54. Ardizzi M, Sestito M, Martini F, Umiltà MA, Ravera R, Gallese V. When age
matters: differences in facial mimicry and autonomic responses to peers'
emotions in teenagers and adults. PLoS One. 2014;9(10):e110763. https://
55. Busch AJ, Balsis S, Morey LC, Oltmanns TF. Gender differences in borderline
personality disorder features in an epidemiological sample of adults age
5564: self versus informant report. J Personal Disord. 2016;30(3):41932
56. Skodol AE, Bender DS. Why are women diagnosed borderline more than
men? Psychiatr Q. 2003;74(4):34960
57. Wrege JS, Ruocco AC, Euler S, Preller KH, Busmann M, Meya L. Negative
affect moderates the effect of social rejection on frontal and anterior
cingulate cortex activation in borderline personality disorder. Cogn
Affect Behav Neurosci. 2019;19(5):113.
58. Waldeck D, Tyndall I, Riva P, Chmiel N. How do we cope with ostracism?
Psychological flexibility moderates the relationship between everyday
ostracism experiences and psychological distress. J Contextual Behav Sci.
59. Riva P, Eck J. Social exclusion. Berlin: Springer; 2016.
60. Zadro L, Boland C, Richardson R. How long does it last? The persistence of
the effects of ostracism in the socially anxious. J Exp Soc Psychol. 2006;42(5):
61. Beauchaine TP. Respiratory sinus arrhythmia: a transdiagnostic biomarker of
emotion dysregulation and psychopathology. Curr Opin Psychol. 2015;3:43
62. Gutz L, Renneberg B, Roepke S, Niedeggen M. Neural processing of social
participation in borderline personality disorder and social anxiety disorder. J
Abnorm Psychol. 2015;124(2):421.
63. Leary MR, Guadagno J. The sociometer, self-esteem, and the regulation of
interpersonal behavior. In Baumeister RF, Vohs K. Handbook of self-
regulation (2nd ed.) New York: Guilford; 2011.
64. Liebke L, Koppe G, Bungert M, Thome J, Hauschild S, Defiebre N. Difficulties
with being socially accepted: an experimental study in borderline
personality disorder. J Abnorm Psychol. 2018;127(7):67082.
65. De Panfilis C, Schito G, Generali I, Gozzi LA, Ossola P, Marchesi C, et al.
Emotions at the border: increased punishment behavior during fair
interpersonal exchanges in borderline personality disorder. J Abnorm
Psychol. 2019;128(2):162.
66. Sadikaj G, Moskowitz DS, Zuroff DC. Attachment-related affective dynamics:
differential reactivity to others' interpersonal behavior. J Pers Soc Psychol.
67. Unoka Z, Seres I, Áspán N, Bódi N, Kéri S. Trust game reveals restricted
interpersonal transactions in patients with borderline personality
disorder. J Personal Disord. 2009;23(4):399409.
68. Fertuck EA, Grinband J, Stanley B. Facial trust appraisal negatively biased in
borderline personality disorder. Psychiatry Res. 2013;207(3):195202. https://
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 13 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
69. Richetin J, Poggi A, Ricciardelli P, Fertuck EA, Preti E. The emotional
components of rejection sensitivity as a mediator between borderline
personality disorder and biased appraisal of trust in faces. Clin
Neuropsychiatry. 2018;15(4):2005.
70. Kernberg OF. Severe personality disorders. New Haven: Yale University Press;
71. Yeomans FE, Clarkin JF, Kernberg OF. Transference-focused psychotherapy
for borderline personality disorder. A clinical guide. Washington, DC:
American Psychiatric Publishing; 2015.
72. Hersh RG, Caligor E, Yeomans FE. Fundamentals of transference-focused
psychotherapy: applications in psychiatric and medical settings. Berlin:
Springer; 2017.
73. Cohen P, Crawford TN, Johnson JG, Kasen S. The children in the community
study of developmental course of personality disorder. J Personal Disord.
74. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The
epidemiology of major depressive disorder: results from the National
Comorbidity Survey Replication (NCS-R). JAMA. 2003;289(23):3095105.
75. Masi CM, Hawkley LC, Rickett EM, Cacioppo JT. Respiratory sinus arrhythmia
and diseases of aging: obesity, diabetes mellitus, and hypertension. Biol
Psychol. 2007;74(2):212223.75
76. Licht CM, de Geus EJ, Zitman FG, Hoogendijk WJ, van Dyck R, Penninx BW.
Association between major depressive disorder and heart rate variability in
the Netherlands study of depression and anxiety (NESDA). Arch Gen
Psychiatry. 2008;65(12):135867
77. Beauchaine TP, Bell Z, Knapton E, McDonough-Caplan H, Shader T, Zisner A.
Respiratory sinus arrhythmia reactivity across empirically based structural
dimensions of psychopathology: a meta-analysis. Psychophysiology. 2019;
78. Prätzlich M, Oldenhof H, Steppan M, Ackermann K, Baker R, Batchelor M,
et al. Resting autonomic nervous system activity is unrelated to antisocial
behaviour dimensions in adolescents: cross-sectional findings from a
European multi-Centre study. J Crim Justice. 2019;65:101536 https://doi.
79. Gyurak A, Ayduk Ö. Resting respiratory sinus arrhythmia buffers against
rejection sensitivity via emotion control. Emotion. 2008;8(4):458. https://doi.
80. De Panfilis C, Meehan KB, Cain NM, Clarkin JF. Effortful control, rejection
sensitivity, and borderline personality disorder features in adulthood. J
Personal Disord. 2016;30(5):595612
81. Rottenberg J, Salomon K, Gross JJ, Gotlib IH. Vagal withdrawal to a sad film
predicts subsequent recovery from depression. Psychophysiology. 2005;
82. Overbeek TJ, van Boxtel A, Westerink JH. Respiratory sinus arrhythmia
responses to cognitive tasks: effects of task factors and RSA indices. Biol
Psychol. 2014;99:114
83. Smith R, Thayer JF, Khalsa SS, Lane RD. The hierarchical basis of
neurovisceral integration. Neurosci Biobehav Rev. 2017;75:27496 https://
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Gerra et al. Borderline Personality Disorder and Emotion Dysregulation (2021) 8:28 Page 14 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
... To our knowledge, until now only one study investigated vagally mediated reactivity to Cyberball-induced social exclusion in patients with BPD [37]. The authors reported decreased RSA values during both inclusion and exclusion phases of the Cyberball task in patients with BPD, while RSA was not affected by Cyberball conditions in HC or depressed patients. ...
... We were therefore interested in how the vagally mediated regulation response was influenced by the underlying emotional-cognitive factor of need threat (threat to fundamental social needs), which served as an individual measure of perceived ostracism across Cyberball conditions. We expected to replicate the findings of decreased vagal tone in patients with BPD compared to HC [35,37]. Furthermore, we expected to observe a vagal response pattern matching the previously demonstrated fight-of-flight reaction of patients with BPD during (perceived) social exclusion, while we expected the opposite pattern for HC as indicative of the more adaptive tend-and-befriend strategy. ...
Full-text available
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.
... These findings indicate an inappropriate activation of the neural social pain circuitries and of fight-orflight physiological states for those with borderline personality disorder during fair or even inclusive interpersonal exchanges that do not match the implicit, unconscious goal of finding perfect relatedness. This conflict is consistently associated with negative subjective reactions, such as increased negative emotions and feelings of social disconnection (34,(36)(37)(38)(39). Usually, the aversive outcomes of conflict signal the need to increase self-regulation by activating goal-directed behavioral responses aimed at reducing the mismatch between one's current and desired states (31). ...
Objective: Transference-focused psychotherapy (TFP) is an empirically supported individualized psychotherapy for patients with borderline personality disorder. This review highlights its development and current status. Methods: A review of the theoretical background underpinning TFP and empirical advances in the development of TFP provide perspective. Results: Otto Kernberg's object relations model of personality and its implications for assessment and diagnosis of personality disorders are described. The authors review the programmatic research that has been developed and has demonstrated the efficacy of TFP. In view of the empirical studies that have demonstrated the successful outcomes and processes of TFP for patients with borderline personality disorder, compared with other approaches, TFP has been applied to a broader range of difficulties related to patients' self-functioning and interpersonal functioning across the range of severities in personality pathology, consistent with the Alternative DSM-5 Model for Personality Disorders. The authors discuss borderline personality organization in the context of interpersonal, neurocognitive, and self-regulatory dysfunction, including preliminary findings. Conclusions: The theoretical and empirical advances in TFP lead to future directions for research evaluating personality disorder and its treatment.
... Some studies have highlighted altered male corticolimbic development after ELA [1], sometimes more so than females [161,162]. Adult men, though less vulnerable to anxiety disorders, exhibit higher prevalence of borderline personality disorder (associated with increased sensitivity to social threat [163]) following paternal maltreatment [164]; this highlights the importance of sex-specific experiences of adversity. Recall that baseline pro-inflammatory effects of ELA also may be more prolonged in males than females; whether heightened inflammatory signaling reflects a sex-specific compensatory mechanism or a contribution to certain types of heightened threat sensitivity throughout the lifespan requires further study. ...
Full-text available
Lifelong indices of maladaptive behavior or illness often stem from early physiological aberrations during periods of dynamic development. This is especially true when dysfunction is attributable to early life adversity (ELA), when the environment itself is unsuitable to support development of healthy behavior. Exposure to ELA is strongly associated with atypical sensitivity and responsivity to potential threats—a characteristic that could be adaptive in situations where early adversity prepares individuals for lifelong danger, but which often manifests in difficulties with emotion regulation and social relationships. By synthesizing findings from animal research, this review will consider threat sensitivity through the lenses of associated corticolimbic brain circuitry and immune mechanisms, both of which are immature early in life to maximize adaptation for protection against environmental challenges to an individual’s well-being. The forces that drive differential development of corticolimbic circuits include caretaking stimuli, physiological and psychological stressors, and sex, which influences developmental trajectories. These same forces direct developmental processes of the immune system, which bidirectionally communicates with sensory systems and emotion regulation circuits within the brain. Inflammatory signals offer a further force influencing the timing and nature of corticolimbic plasticity, while also regulating sensitivity to future threats from the environment (i.e., injury or pathogens). The early development of these systems programs threat sensitivity through juvenility and adolescence, carving paths for probable function throughout adulthood. To strategize prevention or management of maladaptive threat sensitivity in ELA-exposed populations, it is necessary to fully understand these early points of divergence.
Full-text available
Receipt of both positive and negative social feedback is associated with psychophysiological responses, and such responses vary based on levels of internalizing symptoms and associated cognitive constructs. However, research examining the relationship between physiological response to social feedback and internalizing symptoms is mixed, and there is a need to develop salient tasks to assess responses to social feedback. This paper reports on two studies that examined physiological response to social feedback in undergraduate students using the Chatroom Interact Task (CIT). We also explored associations between physiological response to social feedback and internalizing symptoms and associated constructs. Participants were 48 (35 female; Study 1) and 65 (55 female; Study 2) undergraduate students. Participants completed self-report questionnaires of internalizing symptoms and associated cognitive constructs. They also completed the CIT to assess response to acceptance and rejection, while physiological data, including electrocardiogram and respiration to derive respiratory sinus arrhythmia (RSA), were acquired. Results across both studies were largely consistent. There were significant differences in RSA during the questionnaire phase and the neutral and acceptance/rejection phases of the CIT. There were no differences between RSA during acceptance and rejection phases. Internalizing symptoms and associated constructs were not related to differences in RSA. The current study indicates questionable validity for the use of the CIT to elicit heightened physiological responses to social feedback in undergraduates and suggests important considerations for the future study of responses to social feedback and the design of associated tasks.
Full-text available
Social exclusion (ostracism) is a major psychosocial factor contributing to the development and persistence of psychiatric disorders and is also related to their social stigma. However, its specific role in different disorders is not evident, and comprehensive social psychology research on ostracism has rather focused on healthy individuals and less on psychiatric patients. Here, we systematically review experimental studies investigating psychological and physiological reactions to ostracism in different responses of psychiatric disorders. Moreover, we propose a theoretical model of the interplay between psychiatric symptoms and ostracism. A systematic MEDLINE and PsycINFO search was conducted including 52 relevant studies in various disorders (some of which evaluated more than one disorder): borderline personality disorder (21 studies); major depressive disorder (11 studies); anxiety (7 studies); autism spectrum disorder (6 studies); schizophrenia (6 studies); substance use disorders (4 studies); and eating disorders (2 studies). Psychological and physiological effects of ostracism were assessed with various experimental paradigms: e.g., virtual real-time interactions (Cyberball), social feedback and imagined scenarios. We critically review the main results of these studies and propose the overall concept of a vicious cycle where psychiatric symptoms increase the chance of being ostracized, and ostracism consolidates or even aggravates psychopathology. However, the specificity and stability of reactions to ostracism, their neurobiological underpinnings, determinants, and moderators (e.g., attachment style, childhood trauma, and rejection sensitivity) remain elusive.
Full-text available
Patients with borderline personality disorder (BPD) have a heightened sensitivity to social exclusion. Experimental manipulations have produced inconsistent findings and suggested that baseline negative affect (NA) might influence the experience of exclusion. We administered a standardized social exclusion protocol (Cyberball paradigm) in BPD (n = 39) and age-matched and sex-matched healthy controls (n = 29) to investigate the association of NA on social exclusion and activation in brain regions previously implicated in this paradigm. Compared with controls, patients with BPD showed higher activation during social exclusion in the anterior cingulate cortex (ACC), the medial prefrontal cortex (mPFC), and in the right precuneus. Prescan NA ratings were associated with higher brain activation in the ACC and mPFC over all conditions, and post hoc t tests revealed that differences between the groups were only significant when controlling for NA. Brain activation during exclusion was correlated with NA separately for each group. Only BPD patients showed a significant association of NA and exclusion related precuneus activation (r = .52 p = .001). Additionally, BPD patients experienced less feelings of belonging compared with a healthy control (HC) group during inclusion and exclusion, although they estimated their ball possessions significantly higher than did the HC. These findings suggest that baseline NA has a crucial impact on Cyberball-related brain activation. The results underscore the importance of considering levels of NA in social exclusion protocols for participants high in this trait.
Full-text available
Purpose of Review We review recent empirical investigations about two core processes subtending impairments in interpersonal functioning and, more precisely, cooperative behaviors in personality disorders: Trust toward others and rejection sensitivity. The main contributions are about borderline and narcissistic personality disorders but we report little evidence about other personality disorders too (i.e., avoidant, antisocial, and paranoid personality disorders). Recent Findings Regarding borderline personality disorder, a misinterpretation of situations as threatening seems to be relevant for both trust and rejection sensitivity. With specific regards to narcissistic personality disorder, results suggest rejection sensitivity and distrust to be plausible risk factor for aggressive outbursts. Summary Empirical findings display specific pattern of disturbances in rejection sensitivity and trust dynamics across different personality disorders. Nonetheless, further studies on personality disorders other than borderline or narcissistic personality disorder are needed. A deeper understanding may provide insight for better clinical management of such impairments among patients with personality disorders.
Full-text available
Humans engage in social interactions and have a fundamental need and motivation to establish and maintain social connections. Neuroimaging studies particularly focused on the neural substrates of social exclusion in healthy subjects (HC), borderline personality disorder (BPD), and major depression (MD). However, there is evidence regarding neural alterations also during social inclusion in BPD that we intended to elucidate in our study. Considering that patients with BPD often have comorbid MD, we investigated patients with BPD, and comorbid MD, patients with MD without BPD, and a sample of HC. By investigating these two clinical samples within one study design, we attempted to disentangle potential confounds arising by psychiatric disorder or medication and to relate neural alterations under social inclusion specifically to BPD. We investigated 48 females (15 BPD and MD, 16 MD, and 17 HC) aged between 18 and 40 years by fMRI (3T), using the established cyberball paradigm with social exclusion, inclusion, and passive watching conditions. Significant group-by-condition interaction effects (p < 0.05, FWE-corrected on cluster level) were observed within the dorsolateral (dlPFC) and dorsomedial prefrontal cortex (dmPFC), the temporo-parietal junction (TPJ), the posterior cingulate cortex (PCC), and the precuneus. Comparisons of estimated neural activations revealed that significant interaction effects were related to a relative increase in neural activations during social inclusion in BPD. In detail, we observed a significant increase in differential (social inclusion vs. passive watching) neural activation within the dmPFC and the PCC in BPD compared to both, MD and HC. However, significant interaction effects within the dlPFC and the TPJ could not specifically be linked to BPD considering that they did not differ significantly between the two clinical groups in post-hoc comparisons. Our study supports previous results on effects of social and inclusion in BPD, and provides further evidence regarding disorder specific neural alterations in BPD for brain regions associated with self-referential and mentalizing processes during social inclusion.
Full-text available
Objective: Starting from discordant results in the literature, our contribution aims at clarifying the mediating role of rejection sensitivity (RS) in the untrustworthiness bias in Borderline Personality Disorder (BPD). Method: To do so, we examine whether BPD traits are connected to an untrustworthiness bias toward neutral male and female faces in a non clinical sample of young female college students (N = 110). Unlike previous research, we examine the potential role of the different components of RS (emotional and cognitive) separately, and we consider the anger dimension as potentially relevant for trust ratings. Results: Our results demonstrated that only the emotional components (anxiety and anger) and not the cognitive (expectation) mediated the association between BPD traits and trust ratings. Conclusions: We discussed the importance of considering all three components of RS for a better understanding of the relation between BPD and trust appraisal.
Background: Social exclusion (ostracism) can lead to interactional frustration and may play an important role as trigger and symptom amplifier in affective disorders. To investigate immediate emotional and behavioral reactions as well as coping, social exclusion can be mimicked in experimental situations, e.g. in the Cyberball paradigm, a virtual ball tossing game which is well established in social psychology. The present cross-diagnostic study compares the responses to social exclusion in patients with chronic depression (CD), episodic depression (ED) and borderline personality disorder (BPD) in comparison to a healthy control group. Methods: After baseline characterization, 120 participants (29 patients with CD, 20 with ED, 28 with BPD and 43 healthy controls) played Cyberball with two virtual players and complete exclusion after three times receiving the ball. Thereafter, standard questionnaires were applied for measuring needs, threats, inner tension, emotions and behavioral intentions. Results: Patients with CD showed a higher intensity of ostracism and aversive impact, as well as the wish to escape the situation (behavioral intention) compared to ED. In most categories, CD and ED had scores between BPD and healthy controls (with this sequence) and with BPD patients showing the largest difference to healthy controls. Limitations: The assessment did neither include objective behavioral measures (which is a general limitation in the majority of studies using Cyberball) nor any biological variables. The sample sizes of the diagnostic subgroups were moderate. Conclusions: These findings support the hypothesis that social exclusion situations lead to a more aversive emotional and behavioral reaction in CD compared to ED. Psychological and biological underpinnings of these reactions should be addressed in future transdiagnostic studies. Moreover, psychotherapy in CD should focus on specific needs of CD patients for developing a functional coping in threatening interpersonal situations.
The present study aims to test the hypothesis of biological hyperarousal and hyperreactivity underpinning the dysfunctional emotional processes of borderline personality disorder (BPD). Self-reported (quality and intensity of emotions) and physiological (respiratory sinus arrhythmia [RSA] and heart rate) data were collected in 14 clinical subjects with BPD and in 14 control subjects (healthy controls [HCs]), during the administration of six video clips with different emotional contents. Our findings showed a constant hyperarousal state (lower RSA) in the clinical group, supporting the hypothesis of a biological vulnerability to emotional dysregulation. BPD patients showed lower self-reported happiness in positive stimuli compared with HCs and a significant association between emotional dysregulation and physiological hyperreactivity to neutral stimuli. Our data support the hypothesis of a constant condition of physiological preparedness to threat and danger in BPD subjects. Moreover, our results highlight the influence of self-reported ability in regulating emotions in explaining BPD responses to specific emotional situations.
Low resting respiratory sinus arrhythmia (RSA) is observed in many mental health conditions, including anxiety disorders, mood disorders, schizophrenia spectrum disorders, disruptive behavior disorders, and nonsuicidal self-injury, among others. Findings for RSA reactivity are more mixed. We evaluate associations between RSA reactivity and empirically-derived structural categories of psychopathology—including internalizing, externalizing, and thought problems—among physically healthy adults. We searched multiple electronic databases for studies of RSA among participants who were assessed either dimensionally using well-validated measures or diagnostically using structured interviews. Strict inclusion criteria were used to screen 3,605 published reports, which yielded 37 studies including 2,347 participants and 76 effect sizes. We performed a meta-analysis, with meta-analytic regressions of potential moderators, including psychopathology subtypes. The sample-wide meta-analytic association between RSA reactivity and psychopathology was quite small, but heterogeneity was considerable. Moderation analyses revealed significant RSA reactivity (withdrawal) specifically in externalizing samples. Additional moderators included (a) stimulus conditions used to elicit RSA reactivity (only negative emotion inductions were effective), (b) sex (women showed greater RSA reactivity than men), and (c) adherence to established methodological guidelines (e.g., higher electrocardiographic sampling rates yielded greater RSA reactivity). These findings indicate that associations between RSA reactivity and psychopathology are complex, and suggest that future studies should include more standardized RSA assessments to increase external validity and decrease measurement error
This study evaluated whether the impairment in cooperation that characterizes individuals with Borderline Personality Disorder (BPD) can be explained by the difficulty to use emotion regulation strategies and to accurately perceive the fairness of others’ behaviour. Forty-one patients with BPD and forty-one sex and age matched healthy controls (HC) played the responder’s role in a Modified Ultimatum Game (MUG) during which they were asked to apply three different emotion regulation strategies: Look, Distancing and Reappraisal. Offer rejection rates were used as an index of punishment behaviour. After the experiment, participants also rated the degree of perceived equity of the offers after receiving fair and unfair offers. Reappraisal was effective in decreasing punishment behaviours for unfair offers in both the BPD and HC groups. By contrast, BPD patients displayed a different behaviour than HC when making decisions upon fair offers, independently from the regulation strategies adopted. In fact, they rejected higher rates of fair offers than HC. Further, BPD patients judged fair offers as less fair than HC. This indicates an altered judgment and decision making on fair interpersonal exchanges. In conclusion, BPD patients exhibit increased punishment behaviour during fair, “favourable” social exchanges, which they tend to perceive as less fair than controls. Thus, BPD patients may be biased toward under- estimating positive feedback from others.
Anxious preoccupation with real or imagined abandonment is a key feature of borderline personality disorder (BPD). Recent experimental research suggests that patients with BPD do not simply show emotional overreactivity to rejection. Instead, they experience reduced connectedness with others in situations of social inclusion. Resulting consequences of these features on social behavior are not investigated yet. The aim of the present study was to investigate the differential impact of social acceptance and rejection on social expectations and subsequent social behavior in BPD. To this end, we developed the Mannheim Virtual Group Interaction Paradigm in which participants interacted with a group of computer-controlled avatars. They were led to believe that these represented real human coplayers. During these interactions, participants introduced themselves, evaluated their coplayers, assessed their social expectations and received feedback signaling either acceptance or rejection by the alleged other participants. Subsequently, participants played a modified trust game, which measured cooperative and aggressive behavior. Fifty-six nonmedicated BPD patients and 56 healthy control participants were randomly and double-blindly assigned to either the group-acceptance or group-rejection condition. BPD patients showed lower initial expectations of being socially accepted than healthy controls. After repeated presentation of social feedback, they adjusted their expectations in response to negative, but not to positive feedback. After the experience of social acceptance, BPD patients behaved less cooperatively. These experimental findings point to a clinically relevant issue in BPD: Altered cognitive and behavioral responses to social acceptance may hamper the forming of stable cooperative relationships and negatively affect future interpersonal relationships.