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Enhanced Processing of Painful Emotions in Patients With Borderline Personality Disorder: A Functional Magnetic Resonance Imaging Study


Enhanced Processing of Painful Emotions in Patients With Borderline Personality Disorder: A Functional Magnetic Resonance Imaging Study

Vera Flasbeck et al. Front Psychiatry.


Previous research has demonstrated that patients with borderline personality disorder (BPD) are more sensitive to negative emotions and often show poor cognitive empathy, yet preserved or even superior emotional empathy. However, little is known about the neural correlates of empathy. Here, we examined empathy for pain in 20 patients with BPD and 19 healthy controls (HC) in a functional magnetic resonance imaging (fMRI) study, which comprised an empathy for pain paradigm showing facial emotions prior to hands exposed to painful stimuli. We found a selectively enhanced activation of the right supramarginal gyrus for painful hand pictures following painful facial expressions in BPD patients, and lower activation to nonpainful pictures following angry expressions. Patients with BPD showed less activation in the left supramarginal gyrus when viewing angry facial expressions compared to HC, independent of the pain condition. Moreover, we found differential activation of the left anterior insula, depending on the preceding facial expression exclusively in patients. The findings suggest that empathy for pain becomes selectively enhanced, depending on the emotional context information in patients with BPD. Another preliminary finding was an attenuated response to emotions in patients receiving psychotropic medication compared to unmedicated patients. These effects need to be replicated in larger samples. Together, increased activation during the observation of painful facial expressions seems to reflect emotional hypersensitivity in BPD.

Keywords: anterior insula; borderline personality disorder; empathy for pain; functional magnetic resonance imaging; supramarginal gyrus.


Figure 1
Figure 1
Description of the functional magnetic resonance imaging (fMRI) paradigm. Panel (A) shows the timing of one single trial of the empathy for pain paradigm, and Panel (B) shows exemplary pictures used in the paradigm showing the emotions “neutral,” “happy,” “angry,” and “painful” and the painful conditions “pain” and “no pain” for females and males, respectively.
Figure 2
Figure 2
Activation and signal change in percent for regions of interest (ROIs) derived from the contrast (positive effect of pain) for patients with BPD and healthy controls (HC). Regions shown are the left anterior insula (A), the left thalamus (B), and the left and right supramarginal gyri (C). The statistical parametric maps show a threshold of p [uncorr]. < 0.001 for k > 10. The diagram in Panel (D) shows differences between groups for the facial expressions in the left supramarginal gyrus and the diagram in Panel E contains pain and no pain conditions with preceding facial emotions in the right supramarginal gyrus. Note that differences between groups are marked in black, differences within the BPD group are marked in red, and within the control group in blue. We decided to exclude differences between condition (e.g., [angry face+no pain] vs. [angry face+pain] from diagrams to reduce confusing labeling. Error bars represent standard error of the mean (SEM) and *p < 0.05, **p < 0.010, ***p < 0.001.
Figure 3
Figure 3
Activation during emotional face processing in percent signal change for the right supramarginal gyrus in patients with BPD. The diagram compares patients under medication with unmedicated patients. Error bars represent SEM and *p < 0.05, **p < 0.010, ***p < 0.001.

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    1. Sansone RA, Sansone LA. Personality disorders: a nation-based perspective on prevalence. Innov Clin Neurosci (2011) 8(4):13–8 - PMC - PubMed
    1. Gunderson JG. Disturbed relationships as a phenotype for borderline personality disorder. Am J Psychiatry (2007) 164(11):1637–40. 10.1176/appi.ajp.2007.07071125 - DOI - PubMed
    1. Gunderson JG, Links PS. Borderline personality disorder: a clinical guide. Washington DC: American Psychiatric Pub; (2009).
    1. American Psychiatric Association Diagnostic and statistical manual of mental disorders: DSM-5 -5. Washington, DC: American Psychiatric Pub; (2013). 10.1176/appi.books.9780890425596 - DOI
    1. Pagura J, Stein MB, Bolton JM, Cox BJ, Grant B, Sareen J. Comorbidity of borderline personality disorder and posttraumatic stress disorder in the US population. J Psychiatr Res (2010) 44(16):1190–8. 10.1016/j.jpsychires.2010.04.016 - DOI - PMC - PubMed

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