Journal of Personality Disorders, 29, 2015, 194 © 2015 The Guilford Press
AN EMPIRICAL TEST OF REJECTIONAND ANGER-RELATED INTERPRETATION BIAS IN BORDERLINE PERSONALITY DISORDER Jill Lobbestael, PhD, and Richard J. McNally, PhD
The authors tested whether borderline personality disorder (BPD) is characterized by interpretation bias for disambiguating stimuli in favor of threatening interpretations, especially concerning abuse, abandonment, rejection, and anger-core emotional triggers for BPD patients. A mixed sample of 106 patients with marked BPD traits and nonpatients were assessed with SCID I and II and were presented with vignettes depicting ambiguous social interactions. Interpretations of these vignettes were assessed both in a closed and an open answer format. Results showed that BPD traits were related to a rejection- (closed and open answer formats) and an anger-related interpretation bias (closed answer option only). Cluster C traits were associated with self-blame interpretations. Aside from further validating the cognitive model of BPD, these findings denote interpretation bias as a key feature in patients with BPD that might contribute to their emotional hyperreactivity and interpersonal problems. These findings also highlight the importance of therapeutically normalizing interpretative bias in BPD and cluster C patients.
Affecting 1%–2% of the general population and 20% of psychiatric inpatients, borderline personality disorder (BPD) is among the most serious psychological disorders. It is characterized by high therapeutic and medical utilization and substantial suicide rates. People with BPD are emotionally unstable, impulsive, uncertain about their sense of self, and troubled in their relationships with others (American Psychiatric Association [APA], 2013). Because emotional dysregulation is a central feature of BPD (e.g., Linehan, 1993) and because cognitive processes strongly influence emotion (e.g., Ortony, Clore, & Collins, 1988), information-processing models of emotion may illuminate the psychopathology
From Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands (J. L.); and Department of Psychology, Harvard University, Cambridge, Massachusetts (R. J. M.). Jill Lobbestael was supported by a Veni Grant number 451-10-014 of The Netherlands Organisation for Scientific Research (NWO). Thanks are due to Nicky Champagne, Loes Dols, Joyce Deneer, and Maud Peeters for their help in collecting data. Sharon Vaessen, Suzan van der Aa, Jeanine Peeters, Suzanne Brugman, and Michelle van de Glind-Houben were involved in rating the open answers of the vignettes. We are grateful for the collaboration of the board of directors, staff, and patients of the RIAGG Maastricht (Maastricht) and Lianarons (Heerlen) in the Netherlands, and Medisch Centrum Sint-Jozef (Bilzen, Belgium). Address correspondence to Jill Lobbestael, Department of Clinical Psychological Science, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. E-mail: [email protected]
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of BPD. Indeed, psychopathologists have shown that biases in attention, memory, and interpretation figure in the maintenance, and possibly the etiology, of emotional disorders (e.g., Williams, Watts, MacLeod, & Mathews, 1997). For example, a tendency to interpret ambiguous information as threatening may increase a person’s anxiety (e.g., Butler & Mathews, 1983), which, in turn, could lead to interpersonal problems in people who experience difficulty regulating their emotion. Consider a woman with BPD who hears her partner say, “I am leaving the house for a while.” If she has an anxiogenic interpretation bias, she may disambiguate his words as meaning that he is abandoning her forever rather than merely leaving for the store to shop for groceries. Moreover, a tendency to interpret ambiguous information as threatening in people with impaired skills in emotion regulation may cause marked interpersonal conflict. Most work on information-processing biases in people with emotional disorders concerns people with mood and anxiety disorders (e.g., Williams et al., 1997); similar research on BPD is still in its infancy. However, this approach seems helpful for elucidating the development of BPD. First, if someone misinterprets ambiguous situations as threatening, then he or she is likely to react with extreme emotion, as BPD patients tend to do. Second, BPD is closely related to anxiety disorders and to posttraumatic stress disorder (PTSD), due to high levels of childhood maltreatment (Lobbestael, Arntz, & Bernstein, 2010). Because these syndromes are marked by cognitive biases for threat (McNally & Reese, 2009), it stands to reason that they should be evident in BPD too. Cognitive theory holds that the specific focus of interpretation bias is steered by a person’s cognitive schemas. An individual who is vulnerable to social anxiety, for example, will likely interpret ambiguous facial expressions as signs of disapproval. Because cognitive schemas of BPD patients mainly concern abandonment, abuse, rejection, and, to a lesser degree, anger (for an overview, see Lobbestael & Arntz, 2012), these themes seem obvious candidates for steering interpretation bias in BPD patients. Several previous studies experimentally assessed interpretation bias in BPD. Dyck and colleagues (2009) asked BPD patients and nonpatient comparison subjects to evaluate the emotional content of faces. Relative to the comparison group, BPD patients more often misinterpreted neutral faces as expressing negative emotion when evaluations had to be done quickly. Similarly, Domes et al. (2008) found that female BPD patients tended to interpret ambiguous faces as displaying anger. However, several other studies failed to detect an association between interpretation bias for facial cues and BPD (traits) (for an overview, see Mitchell, Dickens, & Picchioni, 2014). Other studies assessed interpretation bias with vignettes in which participants were presented with ambiguous stories. Both BPD and avoidant traits appeared to be associated with a rejection-prone interpretation of vignettes ambiguously signaling social rejection (Meyer, Ajchenbrenner, & Bowles, 2005). One disadvantage of this study, however, was that the questions asked to assess interpretation of the situations may have subtly suggested a negative interpretation. In another vignette study (Arntz, Weertman, & Salet, 2011), participants were asked to imagine an ambiguous, slightly negative event happening to them (e.g., “You experienced something unpleasant yesterday”). In the closed
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response option, participants had to rate their belief in a predefined BPDrelated, obsessive-compulsive related, and an avoidant/dependent-related interpretation. The BPD diagnosis was related to more BPD-related interpretations (e.g., “No one wants to comfort me”) in the closed answer format, and to more critical and malevolent interpretations of others in an open-ended format in which subjects had to furnish their own interpretation of the vignette rather than ranking the likelihood of them endorsing several experimenter-provided interpretations. When involved in an online ball tossing game (Cyberball), BPD patients underestimated how often they received the ball independent of the actual ball tosses compared to nonpatients, which is indicative of a social exclusion bias (Domsalla et al., 2014; Renneberg et al., 2012). Finally, when shown short film clips of persons entering a room and taking a seat, BPD patients evaluated the depicted persons as more aggressive than did depressed patients and nonpatient comparison subjects (Barnow et al., 2009). Taken together, some studies suggest that BPD or BPD traits are related to maladaptive interpretation biases, whereas others do not. However, diversity in the methods of extant studies, including certain procedural limitations, precludes firm conclusions. Accordingly, in the current study, we administered ambiguous social interaction vignettes to a large group of adults comprising psychiatric inpatients, outpatients, and nonpatients. They first provided their interpretation of the vignette in an open-ended format before ranking the experimenter-provided interpretations in terms of their likelihood of endorsing them should the experience in the vignette happen to them. The themes of the vignettes concerned predefined rejection- and anger-related interpretations because fear of being rejected or abandoned and dysregulated anger are both diagnostic criteria of BPD (APA, 2013) that studies have shown relate to BPD (Gardner, Leibenluft, O’Leary, & Cowdry, 1991; Lobbestael & Arntz, 2010). We hypothesized BPD traits to be specifically related to the tendency to interpret ambiguous social situations as rejecting and anger inducing. We also addressed the relationship between the different clusters and interpretation bias, but this was primarily done to allow drawing BPD-specific conclusions, so we had no specific hypothesis concerning these clusters.
METHOD PARTICIPANTS Because taxometric analyses favor a dimensional model of BPD (e.g., Rothschild, Cleland, Haslam, & Zimmerman, 2003), we recruited participants with varying levels of BPD traits. The 106 participants included adults from one psychiatric inpatient unit (n = 14) and two outpatient clinics (n = 68) in The Netherlands and Belgium, resulting in a mixed sample of patients, and participants from the general population (n = 24). Exclusion criteria were alcohol intoxication during testing, the presence of a psychotic disorder, and age less than 18 or above 65 years. Most were women (89.6% versus 10.4% males) and unmarried (64.2% versus 35.8% married). Mean age was 32.7 years (SD = 12.5, range 20–64). With respect to educational level, 3.8% had completed only primary school, 24.5% high school or low-level vocational studies, 63.2% a secondary education, and
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8.5% a higher education. Of all participants, 17% received no diagnosis on Axis I. The remaining 83% received one or more Axis I diagnoses of anxiety disorders (46.2%), mood disorders (53.8%), substance abuse or dependence (2.8%), eating disorders (10.4%), or somatoform disorders (9.4%). Thirtyone percent received no diagnosis on Axis II. The remaining 69% received one or more Axis II diagnoses: borderline (47.2%), avoidant (28.3%), depressive (24.5%), obsessive-compulsive (13.2%), paranoid (12.3%), antisocial (5.7%), passive-aggressive (3.8%), dependent (2.8%), or other personality disorders ( .07), these factors were not included in the regression analyses. The results of the closed answer options from the regression analyses (Table 1) showed that BPD traits positively predicted rejection- and anger-related interpretations, and negatively predicted positive and negative interpretations of the
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TABLE 1. Results of the Forward Regression Analyses With BPD and Personality Disorder (PD) Clusters as Predictors and Interpretation Categories as Dependent Variables for the Closed and Open Vignettes Vignettes type and Interpretation Average scores category M (SD)
Borderline PD traits
Cluster A PD traits
β
p
β
p
−.46*
< .001
−.09
.40
Cluster B PD traits1 β
Cluster C PD traits
p
β
−.04
.67
−.05
.62
p
Closed vignettes Positive
21.45 (5.17)
Anger
18.29 (3.58)
.29*
.007
.19
.14
.24
.02
−.22
.03
Negative
22.30 (3.17)
−.37*
< .001
.04
.73
−.01
.93
.11
.27
Rejection
17.93 (5.11)
.48*
< .001
−.005
.96
−.13
.19
.12
.20
Open vignettes Self-blame
.80 (.82)
−.02
.85
−.09
.40
.06
.52
.28*
.004
3.55 (1.75)
−.31*
.001
−.04
.72
−.01
.91
.04
.68
.32 (.57)
—
—
—
—
—
—
—
—
Anxiety
1.40 (.96)
−.01
.93
−.04
.69
−.02
.87
.20
.04
Positive
1.40 (1.03)
−.05
.63
−.06
.55
−.210
.03
−.02
.86
Control
.44 (.53)
—
—
—
—
—
—
—
—
Negative
.75 (.82)
—
—
—
—
—
—
—
—
Rejection
.90 (1.04)
.28*
.004
.10
.41
.005
.96
−.001
.99
Dislike
.77 (.85)
−.25*
.010
.06
.62
.03
.79
−.04
.67
Anger
1.13 (1.32)
.21
.04
.02
.90
.11
.28
−.06
.53
Neutral Suspicious
Note. Standardized β coefficients are shown; *significant at the Benjamini-Yekutieli FDR-corrected significance level for multiple testing (56) of .01082; 1BPD traits are excluded.
vignettes. The results of the open answer options from the regression analyses (Table 1) showed that BPD traits positively predicted rejection-related interpretations, and negatively predicted neutral and dislike interpretations of the vignettes. Self-blame interpretations were predicted by the number of cluster C PD traits. Suspicious, anxiety, positive, controlling, negative, and anger open interpretations were not significantly predicted by BPD or any of the other personality disorder cluster traits. In order to test whether the presence of comorbid anxiety disorders within the BPD group affected the interpretations, point-biserial correlations were conducted between the dichotomous variable of comorbid anxiety disorder present versus no comorbid anxiety disorder present, on the one hand, and the different open and closed interpretation categories, on the other hand. Results showed that none of these correlations were significant, rpbi values < .22, ps > .12.
DISCUSSION The current study tested whether BPD is characterized by an interpretation bias for disambiguating stimuli in favor of threatening interpretations, especially concerning rejection and anger–core emotional triggers for BPD patients. When participants were instructed to indicate the likelihood of predefined
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interpretations in a closed answer format, BPD traits were related to increased likelihood of both rejection- and anger-related interpretations. When participants were asked to give an open interpretation of the ambiguous social situations, BPD traits were related only to rejection interpretations. These findings further validate the cognitive model of BPD and are largely in line with previous studies indicating a direct relationship between BPD and a rejection (Arntz et al., 2011; Meyer et al., 2005) or aggressive (Arntz et al., 2011; Barnow et al., 2009) interpretation bias. Our study pioneered assessing the specificity of the interpretations for BPD as we controlled statistically for the effects of all other personality disorder clusters. Although BPD interpretations were distorted by both rejection and anger biases, rejection interpretations seemed most salient in BPD. Rejection interpretations were related to BPD without experimental affect priming, and even under the condition of free interpretation (i.e., open vignettes). Accordingly, these data imply that a rejection interpretation bias is a default option, perhaps chronically activated in BPD. This is in line with previous studies denoting the link between BPD and rejection sensitivity, when compared to clinical samples and nonpatients (Staebler, Helbing, Rosenbach, & Renneberg, 2011). The relationship between BPD traits and angry interpretation bias fell just short of significance in the open response option, perhaps because of limited statistical power, or because anger interpretations are less prominent in BPD. Alternatively, angry interpretations may become prominent in BPD patients only after provocation. In line with this view, previous studies found that anger-related attentional bias was only detectable in high trait-anger subjects following insult (Eckhardt & Cohen, 1997). It would be interesting for future studies to test whether a similar effect would emerge on angry interpretation bias in BPD. The detection of rejection- and anger-related biases in the current study extends our understanding of BPD pathology in two ways. First, it is highly likely that rejection-related interpretation bias exerts strong effects on the emotional life of BPD patients. Previous studies confronting BPD patients with actual abusive/rejection triggers incited extreme negative emotions (e.g., Lobbestael & Arntz, 2010). Likewise, in BPD, rejection and rejection sensitivity exert strong effects on a number of emotions and behaviors, such as aversive tension (Stigmayer, Grathwol, Linehan, Ihorst, & Bohus, 2005) and rage (Berenson, Downey, Rafaeli, Coifman, & Leventhal Paquin, 2011). The fact that ambiguous situations are also misinterpreted as rejecting broadens the range of emotionally upsetting triggers in BPD. We thus postulate that emotional reactivity observed in BPD is (partly) caused by a more fundamental rejection-related interpretation bias—a conjecture that awaits experimental testing. Second, interpretation biases may contribute to BPD patients’ interpersonal problems. After all, when neutral acts or statements are interpreted as rejecting or aggressive, this likely elicits highly negative reactions in both the conveyer and the listener. Interpretation biases are therefore probably highly negative for the quality of social relationships of BPD patients. Although biased interpretations can impair current healthy social relationships of these patients, this bias is understandable in view of often chronically adverse childhoods of BPD patients (Lobbestael, Arntz, & Bernstein, 2010). However, this bias becomes maladaptive when patients exhibit it with nonmalevolent people.
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Cluster C PD traits appeared to be associated with a tendency to interpret the vignettes as indicative of self-blame in the open answer option. This is not surprising given the feelings of inadequacy, social ineptness, and inferiority experienced by people with avoidant and dependent PDs. Indeed, people with avoidant PD are highly self-critical to the point of self-loathing; those with dependent PD have little confidence in their ability to cope with life on their own; and those with obsessive-compulsive PTSD are burdened with perfectionistic standards (APA, 2013). Strengths of the current study include participants with a high level of BPD traits, statistical control of other personality disorder cluster traits, and the use of both open and closed answer options. Our study has limitations too. First, although we found no effects of gender, it would have been desirable to have approximately equal numbers of women and men. Second, the internal consistency levels of the negative and anger closed answer options were rather low, which is probably due to the homogeneous negative emotions included in the negative category and the homogeneous reasons outlined for feeling angry in the angry items. Although an independent sample was highly accurate in identifying the intended conceptual differentiation between all closed answer categories, it cannot rule out the possibility that such modest internal reliabilities affected our regression analysis. Third, we did not assess the emotional impact of the vignette task, thereby preventing us from directly testing whether emotional response affected interpretation bias. Finally, parts of the SCID interviews were conducted by graduate students who, although extensively trained, are less clinically experienced than the therapists and diagnosticians who performed the SCID interviews in the clinics. The current study focused merely on assessing the presence of interpretation bias in BPD. Information-processing research on anxiety disorders is much further advanced, and many other issues still await further research in BPD. For one, future studies should assess whether cognitive biases are a specific by-product, a causal factor, or a maintaining factor of BPD. One way to do this is by studying the effect of experimentally manipulating cognitive biases, mirroring anxiety disorder studies (e.g., MacLeod, Rutherford, Campbell, Ebsworthy, & Holker, 2002). Second, cognitive theory assumes that aberrant cognitive schemas drive interpretive bias. Indeed, some studies on avoidant, dependent, and paranoid traits found that the relationships between these traits and disorder-specific interpretation biases were fully mediated by beliefs (e.g., Weertman, Arntz, Schouten, & Dreessen, 2006). Although beliefs of BPD patients concern themes of rejection and abuse (Lobbestael & Arntz, 2012), their possible mediating role for rejection-related interpretation bias remains untested. Alternatively, rejection sensitivity might also be a suitable mediating candidate, given its strong relationship with BPD (Staebler et al., 2011) and negative or hostile interpersonal perception (Ayduk, Downey, Testa, Yen, & Shoda, 1999). Finally, it would be of interest to test whether interpretive retraining can abolish BPD biases, and whether this might diminish the emotional overreactivity of patients and improve their interpersonal relationships. One study using exposure to valenced scenarios, for example, demonstrated that emotional interpretations can be modified (Mathews & Mackintosh, 2000).
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In conclusion, the current study showed that BPD traits were related to rejection- (open and closed conditions) and anger-related (closed condition) interpretations of ambiguous social situations. These interpretation biases may partly explain the emotional hyperreactivity and interpersonal problems observed in BPD. These findings highlight the importance of reducing maladaptive interpretations and replacing them with more functional ones in cognitive therapy.
APPENDIX THE VIGNETTES AND THE CLOSED ANSWER OPTIONS. 1. You wake up in the morning and you see that your partner has left without saying goodbye, which he normally does. • Positive: He is probably out to get fresh bread to surprise you. • Negative: You startle and wonder whether he was late for an important job interview. • Anger: You are angry because he didn’t bother to say goodbye to you. • Rejection: You panic. Maybe he decided to leave you. 2. You have been waiting for almost 45 minutes at the station, and your partner does not show up. You cannot reach him at his cellphone. • Positive: He probably had to wait longer and accidentally forgot to put on his mobile. • Negative: You are afraid something bad might have happened. • Anger: You become angry. It is unacceptable that he lets you wait for so long and does not even bother to put on his mobile phone. • Rejection: Maybe he will not come and he decided to break up with you. 3. You are at a party with your partner. When he returns from the bar, you see that an attractive girl wants to put her arm around his shoulder. Your partner smiles, but pushes her away. • Positive: You are happy your partner is faithful to you. • Negative: You are jealous and immediately approach the girl to show her you are his girlfriend. • Anger: You are angry, approach the girl, and start to insult her. • Rejection: Maybe he finds this woman interesting and considers ending your relationship. 4. Your partner unexpectedly invites you to go to a restaurant. He says he has something important to talk to you about. • Positive: He is very romantic and wants to surprise you. • Negative: Maybe he had a bad meeting with his boss, and he wants to tell you he is fired.
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• Anger: He probably wants to bring up the argument you had the day before and wants to have the last word. • Rejection: You think that “something important” can’t mean something good. You hope he doesn’t want to break up with you. 5. You had a nice day with a new friend. She has promised to call, but you haven’t heard from her in almost 2 weeks. When you call her, she doesn’t answer her phone. • Positive: She probably is very busy at work. You write her an e-mail to invite her for dinner. • Negative: You get worried and call her at her work to check whether she is okay. • Anger: You are angry with her and write her an angry text message. • Rejection: She probably didn’t enjoy the day you spent together, and she doesn’t want to meet with you anymore. You feel abandoned. 6. You and your partner are planning to spend a nice evening together. An hour before you agreed to meet, he calls and says he actually forgot his friend from soccer is throwing a party. • Positive: You don’t mind and accompany him to the party. • Negative: You are disappointed and watch a movie by yourself. • Anger: You are furious and blame him for choosing his friends above his girlfriend. • Rejection: This is a first sign you are not his first priority anymore. You have to be careful not to lose him. 7. While putting the garbage bin outside, you see how your neighbor quickly gets in his car with a suitcase and his wife is crying. • Positive: You think it is nice that the woman still loves her husband so dearly, and she is still sad when he goes on a business trip. • Negative: You are afraid something serious has happened in the neighbors’ family. • Anger: You are angry and think, “The bastard; men always run away after a fight.” • Rejection: You feel pity for the woman who is being left alone with her children. 8. You still have stacks of work to do, and a colleague suggests helping you out. The next day, you notice that your colleague made a lot of mistakes. • Positive: Now you will have to put some more time into it, but you are still happy he has already started. • Negative: You are disappointed that he did such a poor job and will discuss this problem with him. • Anger: You are angry because he appears to have done a very lousy job. • Rejection: It might be best not to mention anything to him, because you might lose his friendship.
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AN EMPIRICAL TEST OF REJECTIONAND ANGER-RELATED INTERPRETATION BIAS IN BORDERLINE PERSONALITY DISORDER Jill Lobbestael, PhD, and Richard J. McNally, PhD
The authors tested whether borderline personality disorder (BPD) is characterized by interpretation bias for disambiguating stimuli in favor of threatening interpretations, especially concerning abuse, abandonment, rejection, and anger-core emotional triggers for BPD patients. A mixed sample of 106 patients with marked BPD traits and nonpatients were assessed with SCID I and II and were presented with vignettes depicting ambiguous social interactions. Interpretations of these vignettes were assessed both in a closed and an open answer format. Results showed that BPD traits were related to a rejection- (closed and open answer formats) and an anger-related interpretation bias (closed answer option only). Cluster C traits were associated with self-blame interpretations. Aside from further validating the cognitive model of BPD, these findings denote interpretation bias as a key feature in patients with BPD that might contribute to their emotional hyperreactivity and interpersonal problems. These findings also highlight the importance of therapeutically normalizing interpretative bias in BPD and cluster C patients.
Affecting 1%–2% of the general population and 20% of psychiatric inpatients, borderline personality disorder (BPD) is among the most serious psychological disorders. It is characterized by high therapeutic and medical utilization and substantial suicide rates. People with BPD are emotionally unstable, impulsive, uncertain about their sense of self, and troubled in their relationships with others (American Psychiatric Association [APA], 2013). Because emotional dysregulation is a central feature of BPD (e.g., Linehan, 1993) and because cognitive processes strongly influence emotion (e.g., Ortony, Clore, & Collins, 1988), information-processing models of emotion may illuminate the psychopathology
From Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands (J. L.); and Department of Psychology, Harvard University, Cambridge, Massachusetts (R. J. M.). Jill Lobbestael was supported by a Veni Grant number 451-10-014 of The Netherlands Organisation for Scientific Research (NWO). Thanks are due to Nicky Champagne, Loes Dols, Joyce Deneer, and Maud Peeters for their help in collecting data. Sharon Vaessen, Suzan van der Aa, Jeanine Peeters, Suzanne Brugman, and Michelle van de Glind-Houben were involved in rating the open answers of the vignettes. We are grateful for the collaboration of the board of directors, staff, and patients of the RIAGG Maastricht (Maastricht) and Lianarons (Heerlen) in the Netherlands, and Medisch Centrum Sint-Jozef (Bilzen, Belgium). Address correspondence to Jill Lobbestael, Department of Clinical Psychological Science, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. E-mail: [email protected]
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of BPD. Indeed, psychopathologists have shown that biases in attention, memory, and interpretation figure in the maintenance, and possibly the etiology, of emotional disorders (e.g., Williams, Watts, MacLeod, & Mathews, 1997). For example, a tendency to interpret ambiguous information as threatening may increase a person’s anxiety (e.g., Butler & Mathews, 1983), which, in turn, could lead to interpersonal problems in people who experience difficulty regulating their emotion. Consider a woman with BPD who hears her partner say, “I am leaving the house for a while.” If she has an anxiogenic interpretation bias, she may disambiguate his words as meaning that he is abandoning her forever rather than merely leaving for the store to shop for groceries. Moreover, a tendency to interpret ambiguous information as threatening in people with impaired skills in emotion regulation may cause marked interpersonal conflict. Most work on information-processing biases in people with emotional disorders concerns people with mood and anxiety disorders (e.g., Williams et al., 1997); similar research on BPD is still in its infancy. However, this approach seems helpful for elucidating the development of BPD. First, if someone misinterprets ambiguous situations as threatening, then he or she is likely to react with extreme emotion, as BPD patients tend to do. Second, BPD is closely related to anxiety disorders and to posttraumatic stress disorder (PTSD), due to high levels of childhood maltreatment (Lobbestael, Arntz, & Bernstein, 2010). Because these syndromes are marked by cognitive biases for threat (McNally & Reese, 2009), it stands to reason that they should be evident in BPD too. Cognitive theory holds that the specific focus of interpretation bias is steered by a person’s cognitive schemas. An individual who is vulnerable to social anxiety, for example, will likely interpret ambiguous facial expressions as signs of disapproval. Because cognitive schemas of BPD patients mainly concern abandonment, abuse, rejection, and, to a lesser degree, anger (for an overview, see Lobbestael & Arntz, 2012), these themes seem obvious candidates for steering interpretation bias in BPD patients. Several previous studies experimentally assessed interpretation bias in BPD. Dyck and colleagues (2009) asked BPD patients and nonpatient comparison subjects to evaluate the emotional content of faces. Relative to the comparison group, BPD patients more often misinterpreted neutral faces as expressing negative emotion when evaluations had to be done quickly. Similarly, Domes et al. (2008) found that female BPD patients tended to interpret ambiguous faces as displaying anger. However, several other studies failed to detect an association between interpretation bias for facial cues and BPD (traits) (for an overview, see Mitchell, Dickens, & Picchioni, 2014). Other studies assessed interpretation bias with vignettes in which participants were presented with ambiguous stories. Both BPD and avoidant traits appeared to be associated with a rejection-prone interpretation of vignettes ambiguously signaling social rejection (Meyer, Ajchenbrenner, & Bowles, 2005). One disadvantage of this study, however, was that the questions asked to assess interpretation of the situations may have subtly suggested a negative interpretation. In another vignette study (Arntz, Weertman, & Salet, 2011), participants were asked to imagine an ambiguous, slightly negative event happening to them (e.g., “You experienced something unpleasant yesterday”). In the closed
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response option, participants had to rate their belief in a predefined BPDrelated, obsessive-compulsive related, and an avoidant/dependent-related interpretation. The BPD diagnosis was related to more BPD-related interpretations (e.g., “No one wants to comfort me”) in the closed answer format, and to more critical and malevolent interpretations of others in an open-ended format in which subjects had to furnish their own interpretation of the vignette rather than ranking the likelihood of them endorsing several experimenter-provided interpretations. When involved in an online ball tossing game (Cyberball), BPD patients underestimated how often they received the ball independent of the actual ball tosses compared to nonpatients, which is indicative of a social exclusion bias (Domsalla et al., 2014; Renneberg et al., 2012). Finally, when shown short film clips of persons entering a room and taking a seat, BPD patients evaluated the depicted persons as more aggressive than did depressed patients and nonpatient comparison subjects (Barnow et al., 2009). Taken together, some studies suggest that BPD or BPD traits are related to maladaptive interpretation biases, whereas others do not. However, diversity in the methods of extant studies, including certain procedural limitations, precludes firm conclusions. Accordingly, in the current study, we administered ambiguous social interaction vignettes to a large group of adults comprising psychiatric inpatients, outpatients, and nonpatients. They first provided their interpretation of the vignette in an open-ended format before ranking the experimenter-provided interpretations in terms of their likelihood of endorsing them should the experience in the vignette happen to them. The themes of the vignettes concerned predefined rejection- and anger-related interpretations because fear of being rejected or abandoned and dysregulated anger are both diagnostic criteria of BPD (APA, 2013) that studies have shown relate to BPD (Gardner, Leibenluft, O’Leary, & Cowdry, 1991; Lobbestael & Arntz, 2010). We hypothesized BPD traits to be specifically related to the tendency to interpret ambiguous social situations as rejecting and anger inducing. We also addressed the relationship between the different clusters and interpretation bias, but this was primarily done to allow drawing BPD-specific conclusions, so we had no specific hypothesis concerning these clusters.
METHOD PARTICIPANTS Because taxometric analyses favor a dimensional model of BPD (e.g., Rothschild, Cleland, Haslam, & Zimmerman, 2003), we recruited participants with varying levels of BPD traits. The 106 participants included adults from one psychiatric inpatient unit (n = 14) and two outpatient clinics (n = 68) in The Netherlands and Belgium, resulting in a mixed sample of patients, and participants from the general population (n = 24). Exclusion criteria were alcohol intoxication during testing, the presence of a psychotic disorder, and age less than 18 or above 65 years. Most were women (89.6% versus 10.4% males) and unmarried (64.2% versus 35.8% married). Mean age was 32.7 years (SD = 12.5, range 20–64). With respect to educational level, 3.8% had completed only primary school, 24.5% high school or low-level vocational studies, 63.2% a secondary education, and
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8.5% a higher education. Of all participants, 17% received no diagnosis on Axis I. The remaining 83% received one or more Axis I diagnoses of anxiety disorders (46.2%), mood disorders (53.8%), substance abuse or dependence (2.8%), eating disorders (10.4%), or somatoform disorders (9.4%). Thirtyone percent received no diagnosis on Axis II. The remaining 69% received one or more Axis II diagnoses: borderline (47.2%), avoidant (28.3%), depressive (24.5%), obsessive-compulsive (13.2%), paranoid (12.3%), antisocial (5.7%), passive-aggressive (3.8%), dependent (2.8%), or other personality disorders ( .07), these factors were not included in the regression analyses. The results of the closed answer options from the regression analyses (Table 1) showed that BPD traits positively predicted rejection- and anger-related interpretations, and negatively predicted positive and negative interpretations of the
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TABLE 1. Results of the Forward Regression Analyses With BPD and Personality Disorder (PD) Clusters as Predictors and Interpretation Categories as Dependent Variables for the Closed and Open Vignettes Vignettes type and Interpretation Average scores category M (SD)
Borderline PD traits
Cluster A PD traits
β
p
β
p
−.46*
< .001
−.09
.40
Cluster B PD traits1 β
Cluster C PD traits
p
β
−.04
.67
−.05
.62
p
Closed vignettes Positive
21.45 (5.17)
Anger
18.29 (3.58)
.29*
.007
.19
.14
.24
.02
−.22
.03
Negative
22.30 (3.17)
−.37*
< .001
.04
.73
−.01
.93
.11
.27
Rejection
17.93 (5.11)
.48*
< .001
−.005
.96
−.13
.19
.12
.20
Open vignettes Self-blame
.80 (.82)
−.02
.85
−.09
.40
.06
.52
.28*
.004
3.55 (1.75)
−.31*
.001
−.04
.72
−.01
.91
.04
.68
.32 (.57)
—
—
—
—
—
—
—
—
Anxiety
1.40 (.96)
−.01
.93
−.04
.69
−.02
.87
.20
.04
Positive
1.40 (1.03)
−.05
.63
−.06
.55
−.210
.03
−.02
.86
Control
.44 (.53)
—
—
—
—
—
—
—
—
Negative
.75 (.82)
—
—
—
—
—
—
—
—
Rejection
.90 (1.04)
.28*
.004
.10
.41
.005
.96
−.001
.99
Dislike
.77 (.85)
−.25*
.010
.06
.62
.03
.79
−.04
.67
Anger
1.13 (1.32)
.21
.04
.02
.90
.11
.28
−.06
.53
Neutral Suspicious
Note. Standardized β coefficients are shown; *significant at the Benjamini-Yekutieli FDR-corrected significance level for multiple testing (56) of .01082; 1BPD traits are excluded.
vignettes. The results of the open answer options from the regression analyses (Table 1) showed that BPD traits positively predicted rejection-related interpretations, and negatively predicted neutral and dislike interpretations of the vignettes. Self-blame interpretations were predicted by the number of cluster C PD traits. Suspicious, anxiety, positive, controlling, negative, and anger open interpretations were not significantly predicted by BPD or any of the other personality disorder cluster traits. In order to test whether the presence of comorbid anxiety disorders within the BPD group affected the interpretations, point-biserial correlations were conducted between the dichotomous variable of comorbid anxiety disorder present versus no comorbid anxiety disorder present, on the one hand, and the different open and closed interpretation categories, on the other hand. Results showed that none of these correlations were significant, rpbi values < .22, ps > .12.
DISCUSSION The current study tested whether BPD is characterized by an interpretation bias for disambiguating stimuli in favor of threatening interpretations, especially concerning rejection and anger–core emotional triggers for BPD patients. When participants were instructed to indicate the likelihood of predefined
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interpretations in a closed answer format, BPD traits were related to increased likelihood of both rejection- and anger-related interpretations. When participants were asked to give an open interpretation of the ambiguous social situations, BPD traits were related only to rejection interpretations. These findings further validate the cognitive model of BPD and are largely in line with previous studies indicating a direct relationship between BPD and a rejection (Arntz et al., 2011; Meyer et al., 2005) or aggressive (Arntz et al., 2011; Barnow et al., 2009) interpretation bias. Our study pioneered assessing the specificity of the interpretations for BPD as we controlled statistically for the effects of all other personality disorder clusters. Although BPD interpretations were distorted by both rejection and anger biases, rejection interpretations seemed most salient in BPD. Rejection interpretations were related to BPD without experimental affect priming, and even under the condition of free interpretation (i.e., open vignettes). Accordingly, these data imply that a rejection interpretation bias is a default option, perhaps chronically activated in BPD. This is in line with previous studies denoting the link between BPD and rejection sensitivity, when compared to clinical samples and nonpatients (Staebler, Helbing, Rosenbach, & Renneberg, 2011). The relationship between BPD traits and angry interpretation bias fell just short of significance in the open response option, perhaps because of limited statistical power, or because anger interpretations are less prominent in BPD. Alternatively, angry interpretations may become prominent in BPD patients only after provocation. In line with this view, previous studies found that anger-related attentional bias was only detectable in high trait-anger subjects following insult (Eckhardt & Cohen, 1997). It would be interesting for future studies to test whether a similar effect would emerge on angry interpretation bias in BPD. The detection of rejection- and anger-related biases in the current study extends our understanding of BPD pathology in two ways. First, it is highly likely that rejection-related interpretation bias exerts strong effects on the emotional life of BPD patients. Previous studies confronting BPD patients with actual abusive/rejection triggers incited extreme negative emotions (e.g., Lobbestael & Arntz, 2010). Likewise, in BPD, rejection and rejection sensitivity exert strong effects on a number of emotions and behaviors, such as aversive tension (Stigmayer, Grathwol, Linehan, Ihorst, & Bohus, 2005) and rage (Berenson, Downey, Rafaeli, Coifman, & Leventhal Paquin, 2011). The fact that ambiguous situations are also misinterpreted as rejecting broadens the range of emotionally upsetting triggers in BPD. We thus postulate that emotional reactivity observed in BPD is (partly) caused by a more fundamental rejection-related interpretation bias—a conjecture that awaits experimental testing. Second, interpretation biases may contribute to BPD patients’ interpersonal problems. After all, when neutral acts or statements are interpreted as rejecting or aggressive, this likely elicits highly negative reactions in both the conveyer and the listener. Interpretation biases are therefore probably highly negative for the quality of social relationships of BPD patients. Although biased interpretations can impair current healthy social relationships of these patients, this bias is understandable in view of often chronically adverse childhoods of BPD patients (Lobbestael, Arntz, & Bernstein, 2010). However, this bias becomes maladaptive when patients exhibit it with nonmalevolent people.
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Cluster C PD traits appeared to be associated with a tendency to interpret the vignettes as indicative of self-blame in the open answer option. This is not surprising given the feelings of inadequacy, social ineptness, and inferiority experienced by people with avoidant and dependent PDs. Indeed, people with avoidant PD are highly self-critical to the point of self-loathing; those with dependent PD have little confidence in their ability to cope with life on their own; and those with obsessive-compulsive PTSD are burdened with perfectionistic standards (APA, 2013). Strengths of the current study include participants with a high level of BPD traits, statistical control of other personality disorder cluster traits, and the use of both open and closed answer options. Our study has limitations too. First, although we found no effects of gender, it would have been desirable to have approximately equal numbers of women and men. Second, the internal consistency levels of the negative and anger closed answer options were rather low, which is probably due to the homogeneous negative emotions included in the negative category and the homogeneous reasons outlined for feeling angry in the angry items. Although an independent sample was highly accurate in identifying the intended conceptual differentiation between all closed answer categories, it cannot rule out the possibility that such modest internal reliabilities affected our regression analysis. Third, we did not assess the emotional impact of the vignette task, thereby preventing us from directly testing whether emotional response affected interpretation bias. Finally, parts of the SCID interviews were conducted by graduate students who, although extensively trained, are less clinically experienced than the therapists and diagnosticians who performed the SCID interviews in the clinics. The current study focused merely on assessing the presence of interpretation bias in BPD. Information-processing research on anxiety disorders is much further advanced, and many other issues still await further research in BPD. For one, future studies should assess whether cognitive biases are a specific by-product, a causal factor, or a maintaining factor of BPD. One way to do this is by studying the effect of experimentally manipulating cognitive biases, mirroring anxiety disorder studies (e.g., MacLeod, Rutherford, Campbell, Ebsworthy, & Holker, 2002). Second, cognitive theory assumes that aberrant cognitive schemas drive interpretive bias. Indeed, some studies on avoidant, dependent, and paranoid traits found that the relationships between these traits and disorder-specific interpretation biases were fully mediated by beliefs (e.g., Weertman, Arntz, Schouten, & Dreessen, 2006). Although beliefs of BPD patients concern themes of rejection and abuse (Lobbestael & Arntz, 2012), their possible mediating role for rejection-related interpretation bias remains untested. Alternatively, rejection sensitivity might also be a suitable mediating candidate, given its strong relationship with BPD (Staebler et al., 2011) and negative or hostile interpersonal perception (Ayduk, Downey, Testa, Yen, & Shoda, 1999). Finally, it would be of interest to test whether interpretive retraining can abolish BPD biases, and whether this might diminish the emotional overreactivity of patients and improve their interpersonal relationships. One study using exposure to valenced scenarios, for example, demonstrated that emotional interpretations can be modified (Mathews & Mackintosh, 2000).
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In conclusion, the current study showed that BPD traits were related to rejection- (open and closed conditions) and anger-related (closed condition) interpretations of ambiguous social situations. These interpretation biases may partly explain the emotional hyperreactivity and interpersonal problems observed in BPD. These findings highlight the importance of reducing maladaptive interpretations and replacing them with more functional ones in cognitive therapy.
APPENDIX THE VIGNETTES AND THE CLOSED ANSWER OPTIONS. 1. You wake up in the morning and you see that your partner has left without saying goodbye, which he normally does. • Positive: He is probably out to get fresh bread to surprise you. • Negative: You startle and wonder whether he was late for an important job interview. • Anger: You are angry because he didn’t bother to say goodbye to you. • Rejection: You panic. Maybe he decided to leave you. 2. You have been waiting for almost 45 minutes at the station, and your partner does not show up. You cannot reach him at his cellphone. • Positive: He probably had to wait longer and accidentally forgot to put on his mobile. • Negative: You are afraid something bad might have happened. • Anger: You become angry. It is unacceptable that he lets you wait for so long and does not even bother to put on his mobile phone. • Rejection: Maybe he will not come and he decided to break up with you. 3. You are at a party with your partner. When he returns from the bar, you see that an attractive girl wants to put her arm around his shoulder. Your partner smiles, but pushes her away. • Positive: You are happy your partner is faithful to you. • Negative: You are jealous and immediately approach the girl to show her you are his girlfriend. • Anger: You are angry, approach the girl, and start to insult her. • Rejection: Maybe he finds this woman interesting and considers ending your relationship. 4. Your partner unexpectedly invites you to go to a restaurant. He says he has something important to talk to you about. • Positive: He is very romantic and wants to surprise you. • Negative: Maybe he had a bad meeting with his boss, and he wants to tell you he is fired.
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• Anger: He probably wants to bring up the argument you had the day before and wants to have the last word. • Rejection: You think that “something important” can’t mean something good. You hope he doesn’t want to break up with you. 5. You had a nice day with a new friend. She has promised to call, but you haven’t heard from her in almost 2 weeks. When you call her, she doesn’t answer her phone. • Positive: She probably is very busy at work. You write her an e-mail to invite her for dinner. • Negative: You get worried and call her at her work to check whether she is okay. • Anger: You are angry with her and write her an angry text message. • Rejection: She probably didn’t enjoy the day you spent together, and she doesn’t want to meet with you anymore. You feel abandoned. 6. You and your partner are planning to spend a nice evening together. An hour before you agreed to meet, he calls and says he actually forgot his friend from soccer is throwing a party. • Positive: You don’t mind and accompany him to the party. • Negative: You are disappointed and watch a movie by yourself. • Anger: You are furious and blame him for choosing his friends above his girlfriend. • Rejection: This is a first sign you are not his first priority anymore. You have to be careful not to lose him. 7. While putting the garbage bin outside, you see how your neighbor quickly gets in his car with a suitcase and his wife is crying. • Positive: You think it is nice that the woman still loves her husband so dearly, and she is still sad when he goes on a business trip. • Negative: You are afraid something serious has happened in the neighbors’ family. • Anger: You are angry and think, “The bastard; men always run away after a fight.” • Rejection: You feel pity for the woman who is being left alone with her children. 8. You still have stacks of work to do, and a colleague suggests helping you out. The next day, you notice that your colleague made a lot of mistakes. • Positive: Now you will have to put some more time into it, but you are still happy he has already started. • Negative: You are disappointed that he did such a poor job and will discuss this problem with him. • Anger: You are angry because he appears to have done a very lousy job. • Rejection: It might be best not to mention anything to him, because you might lose his friendship.
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