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Aggression in Borderline Personality Disorder: A Multidimensional Model

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Aggression in Borderline Personality Disorder: A Multidimensional Model


Personality Disorders: Theory, Research, and Treatment © 2015 American Psychological Association 2015, Vol. 6, No. 3, 278–291 1949-2715/15/$12.00

Aggression in Borderline Personality Disorder: A Multidimensional Model

Falk Mancke, Sabine C. Herpertz, and Katja Bertsch University of Heidelberg

This article proposes a multidimensional model of aggression in borderline personality disorder (BPD) from the perspective of the biobehavioral dimensions of affective dysregulation, impulsivity, threat hypersensitivity, and empathic functioning. It summarizes data from studies that investigated these biobehavioral dimensions using self-reports, behavioral tasks, neuroimaging, neurochemistry as well as psychophysiology, and identifies the following alterations: (a) affective dysregulation associated with prefrontal-limbic imbalance, enhanced heart rate reactivity, skin conductance, and startle response; (b) impulsivity also associated with prefrontal-limbic imbalance, central serotonergic dysfunction, more electroencephalographic slow wave activity, and reduced P300 amplitude in a 2-tone discrimination task; (c) threat hypersensitivity associated with enhanced perception of anger in ambiguous facial expressions, greater speed and number of reflexive eye movements to angry eyes (shown to be compensated by exogenous oxytocin), enhanced P100 amplitude in response to blends of happy versus angry facial expressions, and prefrontal-limbic imbalance; (d) reduced cognitive empathy associated with reduced activity in the superior temporal sulcus/gyrus and preliminary findings of lower oxytocinergic and higher vasopressinergic activity; and (e) reduced self-other differentiation associated with greater emotional simulation and hyperactivation of the somatosensory cortex. These biobehavioral dimensions can be nicely linked to conceptual terms of the alternative Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) model of BPD, and thus to a multidimensional rather than a traditional categorical approach.

Keywords: alternative DSM-5 model of BPD, borderline personality disorder, neurobiology, personality dimension, reactive aggression

Supplemental materials:

Aggression can be defined as any behavior directed toward another individual that is carried out with the proximate intent to cause harm (Anderson & Bushman, 2002). The high prevalence of aggression in borderline personality disorder (BPD) is demon- strated by data showing that 73% of individuals diagnosed with BPD have engaged in aggressive behaviors over the course of a year (Newhill, Eack, & Mulvey, 2009), 58% have been “occasion- ally or often” involved in physical fights, and 25% have used a weapon against others at some point in their lives (Soloff, Meltzer, & Becker, et al., 2003, p. 154). Additionally, individuals with BPD constitute a major proportion of aggression-prone populations such as prison inmates, with prevalence rates of 30% (Black et al., 2007). Studies have found enhanced aggression in BPD compared with healthy and clinical controls irrespective of whether the inclusion was based on categorical Diagnostic and Statistical

Falk Mancke, Sabine C. Herpertz, and Katja Bertsch, Department of General Psychiatry, University of Heidelberg.

This work was supported by two grants of the German Research Foun- dation to Sabine C. Herpertz on borderline personality disorder (Clinical Research Foundation on Mechanisms of Disturbed Emotion Processing in Borderline Personality Disorder,; Schmahl et al., 2014: He 2660/12-1; He 2660/7-2).

Correspondence concerning this article should be addressed to Falk Mancke, Department of General Psychiatry, University of Heidelberg, Voßstraße 2, 69115 Heidelberg, Germany. E-mail: falk.mancke@med.uni-

Manual of Mental Disorders, third edition/fourth edition (DSM– III/IV) diagnosis (e.g., Gardner, Leibenluft, O’Leary, & Cowdry, 1991; McCloskey et al., 2009; Soloff, Kelly, Strotmeyer, Malone, & Mann, 2003) or on dimensional severity scores of BPD traits (e.g., Hines, 2008; Ostrov & Houston, 2008; Raine, 1993; Whis- man & Schonbrun, 2009). Therefore, aggression has been regarded as a core feature of BPD (e.g., Siever et al., 2002; Skodol et al., 2002).

Aggression is most widely classified into instrumental and re- active forms (e.g., Berkowitz, 1993). Instrumental aggression re- fers to planned, goal-directed behavior, whereas reactive aggres- sion is usually triggered by threats, frustration, or provocation and is strongly associated with negative emotions, particularly anger (e.g., Barratt & Felthous, 2003; Poulin & Boivin, 2000). In BPD, aggression is typically of the reactive type (Blair, 2004; Gardner, Archer, & Jackson, 2012; Herpertz et al., 2001). This has also been confirmed by laboratory tests of aggression, in which BPD patients have been repeatedly found to react more aggressively to provo- cations of a (fictitious) opponent compared with healthy individ- uals (Dougherty, Bjork, Huckabee, Moeller, & Swann, 1999; Mc- Closkey et al., 2009; New et al., 2009). There is broad evidence indicating that aggression in BPD is tightly linked to interpersonal dysfunction, with negative interpersonal events (Herr, Keenan- Miller, Rosenthal, & Feldblum, 2013) and interpersonal problems (Stepp, Smith, Morse, Hallquist, & Pilkonis, 2012) predicting subsequent aggressive behavior in subjects scoring high on BPD traits. Additionally, BPD-associated aggression has been shown to


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primarily emerge in close relationships, with most aggressive acts directed against significant others or acquaintances (Newhill et al., 2009). BPD traits were also linked to intimate partner violence in young to late middle-aged individuals (Holtzworth-Munroe, Mee- han, Herron, Rehman, & Stuart, 2000; Ross & Babcock, 2009; Weinstein, Gleason, & Oltmanns, 2012).

DSM-5 offers two concepts of BPD: In Section II (diagnostic criteria and codes), DSM-5 provides a broad analogy to the cate- gorical polythetic classification of BPD in DSM–IV (American Psychiatric Association, 2013, p. 663). The alternative


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