Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Brief report
Facial emotion recognition in borderline personality: An association, with childhood experience Katie Nicol a,n, Merrick Pope b, Jeremy Hall c a
Division of Psychiatry, University of Edinburgh, Kennedy Tower, Royal Edinburgh Hospital, Morningside Park, Edinburgh, EH10 5HF, UK MacKinnon House, Royal Edinburgh Hospital, Morningside Park, Edinburgh EH10 5HF, UK c Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Hadyn Ellis Building, Maindy Road, Cardiff CF24 4HQ, UK b
art ic l e i nf o
a b s t r a c t
Article history: Received 13 May 2013 Received in revised form 3 April 2014 Accepted 7 April 2014
We investigated the relationship between borderline personality disorder (BPD) and childhood adversity using photographs of emotional faces. We found that those with BPD were less able to correctly identify emotional facial expressions, particularly disgust, and that this deficit in BPD correlated significantly with a measure of childhood trauma (CTQ). & 2014 Published by Elsevier Ireland Ltd.
Keywords: Borderline personality disorder Facial emotion recognition Childhood trauma
1. Introduction Previous studies have shown that individuals with a diagnosis of borderline personality disorder (BPD) have difficulty recognising facial emotions (Bland et al., 2004) which may relate to disturbed emotional development (Crowell et al., 2009). Brain areas involved in emotion processing show extensive development across childhood and adolescence and have been found to be structurally and functionally altered in people with BPD compared to controls (Hall et al., 2010; Mauchnik and Schmahl, 2010; Nunes et al., 2009). These areas have also recently been shown to be affected by adverse events in childhood (Ansell et al., 2012) further suggesting a link between developmental experience and BPD. However, emotion processing deficits in BPD have not previously been directly investigated in relation to measures of childhood experience.
2. Methods Twenty participants with BPD were recruited from outpatient populations. The diagnosis of BPD was confirmed using the SCID-II, and participants were additionally screened for comorbidity using the SCID-I and by reviewing medical notes. Of 20 participants, 15 were female and five were male, with mean age 34.3 years (S.D. 8.5) and mean IQ 115.9 (S.D. 7.4). Comorbid diagnoses were present in ten individuals in the BPD group and included bipolar affective disorder type II (4), obsessive compulsive disorder (2), post-traumatic stress disorder (2), eating
n
Corresponding author. Tel.: þ 44 131 537 6187. E-mail address: [email protected] (K. Nicol).
disorder (6), panic disorder (1), paranoid personality disorder (1) and avoidant personality disorder (1). Twenty-one healthy controls were recruited from community volunteers, comprising 16 females and five males. Mean age for the control group was 34.5 years (S.D. 11.6) and mean IQ was 114.2 (S.D. 7.3). Within the BPD group, a total of sixteen individuals were being treated with medication, with 11 receiving antipsychotic drug treatment and 13 receiving antidepressant drug treatment. Exclusion criteria for all participants included diagnosis of any other axis I psychiatric illness, drug or alcohol dependency, and any other neurological illness or serious head injury. All participants were aged between 18 and 65. Participants completed the Ekman 60 Faces test (Young et al., 2010), in which one of six emotions was identified from each photograph in a series of 60 faces depicting either anger, disgust, fear, happiness, sadness or surprise. Faces appeared on a computer screen for 3 s each, in a randomised order. The names of all six emotions were listed on the screen, and subjects made a selection by clicking the mouse over the desired name. The next face was not shown until a selection had been made. Participants were shown six practice images, covering the six emotions, which were not included in analysis. In addition to emotion testing, all participants were asked to complete three questionnaires – the Hamilton Rating Scale for Depression (HAM-D), the Young Mania rating scale (YMRS) and the Childhood Trauma Questionnaire (CTQ). The CTQ is a self-report measure consisting of 18 questions relating to childhood experience of abuse and neglect. Due to the potentially arousing nature of the questions, all participants were issued a help and contact sheet and offered subsequent support if required. Statistical tests were performed using SPSS (version 19) for Windows. ANOVA was used to test for differences between groups. Where individual conditions (e.g., emotion) were compared, T-tests were used.
3. Results There was no difference in age (t1,39 ¼ 0.07, p ¼0.94) or IQ (t1,37 ¼ 0.73, p ¼ 0.47) between groups. The BPD group scored
http://dx.doi.org/10.1016/j.psychres.2014.04.017 0165-1781/& 2014 Published by Elsevier Ireland Ltd.
Please cite this article as: Nicol, K., et al., Facial emotion recognition in borderline personality: An association, with childhood experience. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.04.017i
K. Nicol et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
2
Fig. 1. Percentage of maximum score available attained by BPD and control groups in a test of facial emotion recognition.The highly significant difference in results between groups for disgust recognition (p o 0.001) drives the total difference in scores between groups (p o 0.05).
significantly higher than controls on the HAM-D (t1,39 ¼ 7.77, p o0.001), the YMRS (t1,39 ¼ 4.83, p o0.001) and the CTQ (t1,39 ¼9.39, p o0.001). Repeated measures ANOVA was used to analyse subjects’ performance in the Ekman 60 Faces test, with group (BPD/control) as the between subjects factor and stimulus (emotion) as within subjects variable. The results showed significant effects of emotion (F5,195 ¼17.4, p o0.001) and group (F1,39 ¼ 6.2, p ¼0.02), and an emotion group interaction (F5,195 ¼2.7, p¼ 0.02). Further analysis by post-hoc T-tests revealed that the overall group effect was contributed substantially by impaired recognition of disgust in the BPD group (t1,39 ¼ 3.5, p ¼0.001), with no other emotion reaching significance (Fig. 1). The deficit in disgust recognition remained significant following application of the Bonferroni correction for multiple comparisons (p corrected o0.01). We next investigated the relationship between childhood trauma, as measured by the CTQ, and emotion recognition in BPD. Total CTQ scores were found to correlate with Ekman 60 Faces test performance in the BPD group, with poorer performance associated with a higher CTQ score (r¼ 0.48, p ¼0.03). Following separation of the CTQ questions into five subgroups, significant correlations were apparent between emotion recognition (Ekman 60 Faces test score) and physical abuse (r ¼ 0.49, p ¼0.03), as well as emotional abuse (r ¼ 0.48, p ¼0.03), but not between emotion recognition and sexual abuse (r ¼ 0.33, p ¼0.15), physical neglect (r ¼ 0.11, p ¼0.67) or emotional neglect (r ¼ 0.21, p ¼0.37). Correlation analysis between CTQ scores and individual emotions in the BPD group revealed that disgust recognition was the main contributor to the overall significant relationships between emotion recognition and total CTQ score (r ¼ 0.47, p ¼0.04), the physical abuse subscale (r ¼ 0.49, p ¼0.03), and the emotional abuse subscale (r ¼ 0.48, p ¼0.03). There was no significant correlation between any of the other specific emotions and CTQ scores in those with BPD and no significant correlation was found between performance on the Ekman 60 Faces test and either the Hamilton Rating Scale for Depression (r ¼ 0.21, p ¼0.38, or the Young Mania Rating Scale (r ¼0.05, p¼ 0.83). Correlation analysis was not carried out on the control group data due to insufficient range of CTQ scores, and to prevent type 1 errors.
4. Discussion Individuals with a diagnosis of BPD performed less well than control participants in the Ekman 60 test of facial emotion
recognition. Recognition of disgust was particularly impaired, and this deficit was found to correlate with CTQ score in the BPD group. Following separation of the CTQ questions into their five subgroups – physical abuse, emotional abuse, sexual abuse, physical neglect and emotional neglect – we found that only scores relating to physical abuse and emotional abuse correlated significantly with emotion recognition in the BPD group. These results suggest that childhood experience has a lasting effect on the emotional brain, and that negative experiences may contribute to the symptoms experienced by those with BPD in adulthood. In particular, difficulties in correctly recognising facial emotions is likely to play a part in the social difficulties suffered by individuals with BPD, as such a large amount of the information we glean about others comes from the face (Young and Bruce, 2011). Neural processing of disgust involves the insular cortex (Ibanez et al., 2010), an area of the brain which is also associated with empathy and perception of pain, and which has been shown to have altered function in studies of BPD. Recent evidence also suggests that changes in the structure of the insular cortex may be related to early-life trauma (Ansell et al., 2012), and Olesen et al. (2010) have shown that prolonged experience of pain leads to functional reorganisation of this area. The current findings, of a highly significant correlation between CTQ score and disgust recognition in the BPD group, indicate that childhood trauma may play a part in altered insular cortex structure or functional reorganisation, leading to difficulties in emotion processing in this area. Overall, the present findings demonstrate that people with BPD have difficulty correctly perceiving emotions in faces, particularly the emotion of disgust, and that this difficulty is associated with traumatic childhood experiences. Further work is necessary to gain a more complete understanding of the association between disgust, BPD and childhood trauma. Given the relatively small sample size of the present study, replication of the results involving a greater number of participants would be helpful. Further measures of disgust, as well as neuroimaging studies of this population, may also help us to discern specifically which neural processes are dysfunctional in disgust recognition in BPD, and how childhood trauma is related.
Conflict of interest None.
Acknowledgements The study was funded by a Grant from the Chief Scientist office of Scotland (Grant no. SCD/10). Additional support was provided by the Scottish Mental Health Research Network. JH is supported by a Scottish Senior Clinical Fellowship. We additionally thank all the participants. References Ansell, E.B., Rando, K., Tuit, K., Guarnaccia, J., Sinha, R., 2012. Cumulative adversity and smaller grey matter volume in medial prefrontal, anterior cingulate, and insula regions. Biological Psychiatry 72 (1), 57–64. Bland, A.R., Williams, C.A., Scharer, K., Manning, S., 2004. Emotion processing in borderline personality disorders. Issues in Mental Health Nursing 25, 655–672. Crowell, S.E., Beauchaine, T.P., Linehan, M.M., 2009. A biosocial development model of borderline personality: elaborating and extending Linehan's theory. Psychological Bulletin 135 (3), 495–510. Hall, J., Olabi, B., Lawrie, S.M., McIntosh, A.M., 2010. Hippocampal and amygdala volumes in borderline personality disorder: a meta-analysis of magnetic resonance imaging studies. Personality and Mental Health 4 (3), 172–179.
Please cite this article as: Nicol, K., et al., Facial emotion recognition in borderline personality: An association, with childhood experience. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.04.017i
K. Nicol et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎ Ibanez, A., Gleichgerrcht, E., Manes, F., 2010. Clinical effects of insular damage in humans. Brain Structure and Function 214, 397–410. Mauchnik, J., Schmahl, C., 2010. The latest neuroimaging findings in borderline personality disorder. Current Psychiatry Reports 12, 46–55. Nunes, P.M., Wenzel, A., Borges, K.T., Porto, C.R., Caminha, R.M., de Oliveira, I.R., 2009. Volumes of the hippocampus and amygdala in borderline personality disorder: a meta-analysis. Journal of Personality Disorders 23 (4), 333–345.
3
Olesen, S.S., Frøkjær, J.B., Lelic, D., Valeriani, M., Drewes, A.M., 2010. Pain-associated adaptive cortical reorganisation in chronic pancreatitis. Pancreatology 10 (6), 742–751. Young, A.W., Perrett, D.I., Calder, A.J., Sprengelmeyer, R., Ekman, P., 2010. Facial Expressions of Emotion: Stimuli and Tests (FEEST). Thames Valley Test Company, Bury St. Edmunds. Young, A.W., Bruce, V., 2011. Understanding person perception. British Journal of Psychology 102, 959–974.
Please cite this article as: Nicol, K., et al., Facial emotion recognition in borderline personality: An association, with childhood experience. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.04.017i
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Brief report
Facial emotion recognition in borderline personality: An association, with childhood experience Katie Nicol a,n, Merrick Pope b, Jeremy Hall c a
Division of Psychiatry, University of Edinburgh, Kennedy Tower, Royal Edinburgh Hospital, Morningside Park, Edinburgh, EH10 5HF, UK MacKinnon House, Royal Edinburgh Hospital, Morningside Park, Edinburgh EH10 5HF, UK c Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Hadyn Ellis Building, Maindy Road, Cardiff CF24 4HQ, UK b
art ic l e i nf o
a b s t r a c t
Article history: Received 13 May 2013 Received in revised form 3 April 2014 Accepted 7 April 2014
We investigated the relationship between borderline personality disorder (BPD) and childhood adversity using photographs of emotional faces. We found that those with BPD were less able to correctly identify emotional facial expressions, particularly disgust, and that this deficit in BPD correlated significantly with a measure of childhood trauma (CTQ). & 2014 Published by Elsevier Ireland Ltd.
Keywords: Borderline personality disorder Facial emotion recognition Childhood trauma
1. Introduction Previous studies have shown that individuals with a diagnosis of borderline personality disorder (BPD) have difficulty recognising facial emotions (Bland et al., 2004) which may relate to disturbed emotional development (Crowell et al., 2009). Brain areas involved in emotion processing show extensive development across childhood and adolescence and have been found to be structurally and functionally altered in people with BPD compared to controls (Hall et al., 2010; Mauchnik and Schmahl, 2010; Nunes et al., 2009). These areas have also recently been shown to be affected by adverse events in childhood (Ansell et al., 2012) further suggesting a link between developmental experience and BPD. However, emotion processing deficits in BPD have not previously been directly investigated in relation to measures of childhood experience.
2. Methods Twenty participants with BPD were recruited from outpatient populations. The diagnosis of BPD was confirmed using the SCID-II, and participants were additionally screened for comorbidity using the SCID-I and by reviewing medical notes. Of 20 participants, 15 were female and five were male, with mean age 34.3 years (S.D. 8.5) and mean IQ 115.9 (S.D. 7.4). Comorbid diagnoses were present in ten individuals in the BPD group and included bipolar affective disorder type II (4), obsessive compulsive disorder (2), post-traumatic stress disorder (2), eating
n
Corresponding author. Tel.: þ 44 131 537 6187. E-mail address: [email protected] (K. Nicol).
disorder (6), panic disorder (1), paranoid personality disorder (1) and avoidant personality disorder (1). Twenty-one healthy controls were recruited from community volunteers, comprising 16 females and five males. Mean age for the control group was 34.5 years (S.D. 11.6) and mean IQ was 114.2 (S.D. 7.3). Within the BPD group, a total of sixteen individuals were being treated with medication, with 11 receiving antipsychotic drug treatment and 13 receiving antidepressant drug treatment. Exclusion criteria for all participants included diagnosis of any other axis I psychiatric illness, drug or alcohol dependency, and any other neurological illness or serious head injury. All participants were aged between 18 and 65. Participants completed the Ekman 60 Faces test (Young et al., 2010), in which one of six emotions was identified from each photograph in a series of 60 faces depicting either anger, disgust, fear, happiness, sadness or surprise. Faces appeared on a computer screen for 3 s each, in a randomised order. The names of all six emotions were listed on the screen, and subjects made a selection by clicking the mouse over the desired name. The next face was not shown until a selection had been made. Participants were shown six practice images, covering the six emotions, which were not included in analysis. In addition to emotion testing, all participants were asked to complete three questionnaires – the Hamilton Rating Scale for Depression (HAM-D), the Young Mania rating scale (YMRS) and the Childhood Trauma Questionnaire (CTQ). The CTQ is a self-report measure consisting of 18 questions relating to childhood experience of abuse and neglect. Due to the potentially arousing nature of the questions, all participants were issued a help and contact sheet and offered subsequent support if required. Statistical tests were performed using SPSS (version 19) for Windows. ANOVA was used to test for differences between groups. Where individual conditions (e.g., emotion) were compared, T-tests were used.
3. Results There was no difference in age (t1,39 ¼ 0.07, p ¼0.94) or IQ (t1,37 ¼ 0.73, p ¼ 0.47) between groups. The BPD group scored
http://dx.doi.org/10.1016/j.psychres.2014.04.017 0165-1781/& 2014 Published by Elsevier Ireland Ltd.
Please cite this article as: Nicol, K., et al., Facial emotion recognition in borderline personality: An association, with childhood experience. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.04.017i
K. Nicol et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
2
Fig. 1. Percentage of maximum score available attained by BPD and control groups in a test of facial emotion recognition.The highly significant difference in results between groups for disgust recognition (p o 0.001) drives the total difference in scores between groups (p o 0.05).
significantly higher than controls on the HAM-D (t1,39 ¼ 7.77, p o0.001), the YMRS (t1,39 ¼ 4.83, p o0.001) and the CTQ (t1,39 ¼9.39, p o0.001). Repeated measures ANOVA was used to analyse subjects’ performance in the Ekman 60 Faces test, with group (BPD/control) as the between subjects factor and stimulus (emotion) as within subjects variable. The results showed significant effects of emotion (F5,195 ¼17.4, p o0.001) and group (F1,39 ¼ 6.2, p ¼0.02), and an emotion group interaction (F5,195 ¼2.7, p¼ 0.02). Further analysis by post-hoc T-tests revealed that the overall group effect was contributed substantially by impaired recognition of disgust in the BPD group (t1,39 ¼ 3.5, p ¼0.001), with no other emotion reaching significance (Fig. 1). The deficit in disgust recognition remained significant following application of the Bonferroni correction for multiple comparisons (p corrected o0.01). We next investigated the relationship between childhood trauma, as measured by the CTQ, and emotion recognition in BPD. Total CTQ scores were found to correlate with Ekman 60 Faces test performance in the BPD group, with poorer performance associated with a higher CTQ score (r¼ 0.48, p ¼0.03). Following separation of the CTQ questions into five subgroups, significant correlations were apparent between emotion recognition (Ekman 60 Faces test score) and physical abuse (r ¼ 0.49, p ¼0.03), as well as emotional abuse (r ¼ 0.48, p ¼0.03), but not between emotion recognition and sexual abuse (r ¼ 0.33, p ¼0.15), physical neglect (r ¼ 0.11, p ¼0.67) or emotional neglect (r ¼ 0.21, p ¼0.37). Correlation analysis between CTQ scores and individual emotions in the BPD group revealed that disgust recognition was the main contributor to the overall significant relationships between emotion recognition and total CTQ score (r ¼ 0.47, p ¼0.04), the physical abuse subscale (r ¼ 0.49, p ¼0.03), and the emotional abuse subscale (r ¼ 0.48, p ¼0.03). There was no significant correlation between any of the other specific emotions and CTQ scores in those with BPD and no significant correlation was found between performance on the Ekman 60 Faces test and either the Hamilton Rating Scale for Depression (r ¼ 0.21, p ¼0.38, or the Young Mania Rating Scale (r ¼0.05, p¼ 0.83). Correlation analysis was not carried out on the control group data due to insufficient range of CTQ scores, and to prevent type 1 errors.
4. Discussion Individuals with a diagnosis of BPD performed less well than control participants in the Ekman 60 test of facial emotion
recognition. Recognition of disgust was particularly impaired, and this deficit was found to correlate with CTQ score in the BPD group. Following separation of the CTQ questions into their five subgroups – physical abuse, emotional abuse, sexual abuse, physical neglect and emotional neglect – we found that only scores relating to physical abuse and emotional abuse correlated significantly with emotion recognition in the BPD group. These results suggest that childhood experience has a lasting effect on the emotional brain, and that negative experiences may contribute to the symptoms experienced by those with BPD in adulthood. In particular, difficulties in correctly recognising facial emotions is likely to play a part in the social difficulties suffered by individuals with BPD, as such a large amount of the information we glean about others comes from the face (Young and Bruce, 2011). Neural processing of disgust involves the insular cortex (Ibanez et al., 2010), an area of the brain which is also associated with empathy and perception of pain, and which has been shown to have altered function in studies of BPD. Recent evidence also suggests that changes in the structure of the insular cortex may be related to early-life trauma (Ansell et al., 2012), and Olesen et al. (2010) have shown that prolonged experience of pain leads to functional reorganisation of this area. The current findings, of a highly significant correlation between CTQ score and disgust recognition in the BPD group, indicate that childhood trauma may play a part in altered insular cortex structure or functional reorganisation, leading to difficulties in emotion processing in this area. Overall, the present findings demonstrate that people with BPD have difficulty correctly perceiving emotions in faces, particularly the emotion of disgust, and that this difficulty is associated with traumatic childhood experiences. Further work is necessary to gain a more complete understanding of the association between disgust, BPD and childhood trauma. Given the relatively small sample size of the present study, replication of the results involving a greater number of participants would be helpful. Further measures of disgust, as well as neuroimaging studies of this population, may also help us to discern specifically which neural processes are dysfunctional in disgust recognition in BPD, and how childhood trauma is related.
Conflict of interest None.
Acknowledgements The study was funded by a Grant from the Chief Scientist office of Scotland (Grant no. SCD/10). Additional support was provided by the Scottish Mental Health Research Network. JH is supported by a Scottish Senior Clinical Fellowship. We additionally thank all the participants. References Ansell, E.B., Rando, K., Tuit, K., Guarnaccia, J., Sinha, R., 2012. Cumulative adversity and smaller grey matter volume in medial prefrontal, anterior cingulate, and insula regions. Biological Psychiatry 72 (1), 57–64. Bland, A.R., Williams, C.A., Scharer, K., Manning, S., 2004. Emotion processing in borderline personality disorders. Issues in Mental Health Nursing 25, 655–672. Crowell, S.E., Beauchaine, T.P., Linehan, M.M., 2009. A biosocial development model of borderline personality: elaborating and extending Linehan's theory. Psychological Bulletin 135 (3), 495–510. Hall, J., Olabi, B., Lawrie, S.M., McIntosh, A.M., 2010. Hippocampal and amygdala volumes in borderline personality disorder: a meta-analysis of magnetic resonance imaging studies. Personality and Mental Health 4 (3), 172–179.
Please cite this article as: Nicol, K., et al., Facial emotion recognition in borderline personality: An association, with childhood experience. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.04.017i
K. Nicol et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎ Ibanez, A., Gleichgerrcht, E., Manes, F., 2010. Clinical effects of insular damage in humans. Brain Structure and Function 214, 397–410. Mauchnik, J., Schmahl, C., 2010. The latest neuroimaging findings in borderline personality disorder. Current Psychiatry Reports 12, 46–55. Nunes, P.M., Wenzel, A., Borges, K.T., Porto, C.R., Caminha, R.M., de Oliveira, I.R., 2009. Volumes of the hippocampus and amygdala in borderline personality disorder: a meta-analysis. Journal of Personality Disorders 23 (4), 333–345.
3
Olesen, S.S., Frøkjær, J.B., Lelic, D., Valeriani, M., Drewes, A.M., 2010. Pain-associated adaptive cortical reorganisation in chronic pancreatitis. Pancreatology 10 (6), 742–751. Young, A.W., Perrett, D.I., Calder, A.J., Sprengelmeyer, R., Ekman, P., 2010. Facial Expressions of Emotion: Stimuli and Tests (FEEST). Thames Valley Test Company, Bury St. Edmunds. Young, A.W., Bruce, V., 2011. Understanding person perception. British Journal of Psychology 102, 959–974.
Please cite this article as: Nicol, K., et al., Facial emotion recognition in borderline personality: An association, with childhood experience. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.04.017i
