Too Good to Be True? Unpacking the Processing of Positive Social Information in Borderline Personality Disorder and Social Anxiety Disorder

A hallmark feature of individuals with borderline personality disorder (BPD) and social anxiety disorder (SAD) are severe interpersonal problems. According to cognitive theories, interpersonal problems are caused by biases in the processing of social information. Indeed, previous research has shown that individuals with BPD and SAD tend to process social information in a biased manner. For example, compared to individuals without a mental disorder, individuals with BPD evaluate facial expressions more negatively, and individuals with SAD direct their attention faster towards negative facial expressions. However, little is known about the processing of positive social information in BPD and SAD, and no study has compared the processing of positive social information between both disorders so far. The aim of this thesis is to unpack biases in the processing of positive social information in BPD and SAD in order to understand the nature of their interpersonal problems in more detail. To this end, the three studies presented in this thesis compared the processing of two specific types of positive social information – inclusive social situations and positive social feedback – between individuals with BPD and SAD. In the long term, these insights on shared as well as disorder-specific biases will help to treat interpersonal problems in BPD and SAD more effectively. Study 1 and study 2 examined whether individuals with BPD and SAD process inclusive social situations in a biased manner. Inclusive situations were operationalized as social inclusion (being equally included into a group) and social overinclusion (being overly included into a group). Structured clinical interviews were conducted to compare the processing of social inclusion and overinclusion among three groups: Participants with BPD (n = 29), participants with SAD (n = 28) and healthy controls (HCs; n = 28). All 85 participants played two rounds of the well-established Cyberball paradigm, an online ball-tossing game. In the first round, participants received the ball as often as their virtual co-players did (social inclusion); in the second round, participants received the ball more often than the co-players did (social overinclusion). In addition to self-report data, electroencephalography data was assessed. This enabled the examination of event-related potentials associated with the processing of inclusive social situations. Event-related potentials of interest were the P2 amplitude, an indicator for reward processing, and the P3 amplitude, an indicator for expectancy violation. Results of study 1 showed an enhanced P3 amplitude in participants with BPD and SAD irrespective of the condition (inclusion and overinclusion). This indicates that individuals with BPD and SAD tend to expect exclusion even if they find themselves in inclusive social situations. Self-report data revealed that participants with BPD and SAD emotionally responded more negatively to social inclusion, while their emotional response to social overinclusion mostly did not differ from HCs. Results of study 2 showed that the transition from social inclusion to social overinclusion was accompanied by an enhanced P2 amplitude in participants with BPD and HCs, but not in participants with SAD. This indicates that an increase in the level of social inclusion is perceived as rewarding by individuals with BPD and individuals without a mental disorder, but not by individuals with SAD. However, the increase in the level of social inclusion did not affect self-reported positive emotions and it is necessary to further clarify the association between the P2 amplitude and reward processing. Study 3 examined whether individuals with BPD and SAD fear positive social feedback. One hundred participants (three groups: 36 participants with BPD, 29 participants with SAD, 35 HCs) took part in an online assessment. Results of the Fear of Positive Evaluation Scale showed that individuals with BPD and individuals with SAD highly fear positive feedback. A hierarchical regression analysis further indicated that social anxiety explains high fear of positive feedback in BPD and SAD. In summary, the findings of this thesis point towards shared as well as disorder-specific biases in the processing of positive social information in BPD and SAD. On the one hand, individuals with BPD and individuals with SAD seem to process inclusive social situations in a biased manner. That is, they expect to be excluded even in inclusive social situations and emotionally respond to social inclusion more negatively. Furthermore, individuals with SAD and individuals with BPD seem to be afraid of positive social feedback. On the other hand, findings indicate that specifically individuals with SAD might not benefit from an increase in the level of social inclusion. On a general level, the findings of this thesis indicate that both disorders are characterized by negative social expectations (i.e., the expectation to be excluded) and maladaptive emotions (i.e., fear of positive feedback) even in the processing of positive social information. This knowledge is important for clinical practice. For a start, therapists should be aware that their patients tend to process positive social information in a biased manner, which might contribute to their interpersonal problems

Processing of increased frequency of social interaction in social anxiety disorder and borderline personality disorder

We investigated how patients with social anxiety disorder (SAD) and patients with borderline personality disorder (BPD) process an increase in the frequency of social interaction. We used an EEG-compatible version of the online ball-tossing game Cyberball to induce an increase in the frequency of social interaction. In the first condition, each player received the ball equally often (inclusion: 33% ball reception). In the following condition, the frequency of the ball reception was increased (overinclusion: 45% ball reception). The main outcome variable was the event-related potential P2, an indicator for social reward processing. Moreover, positive emotions were assessed. Twenty-eight patients with SAD, 29 patients with BPD and 28 healthy controls (HCs) participated. As expected, HCs and patients with BPD, but not patients with SAD, showed an increase in the P2 amplitude from the inclusion to the overinclusion condition. Contrary to our expectations, positive emotions did not change from the inclusion to the overinclusion condition. EEG results provide preliminary evidence that patients with BPD and HCs, but not patients with SAD, process an increase in the frequency of social interaction as rewarding

Fear of positive evaluation in borderline personality disorder

Background: Being afraid of others’ positive appraisal of oneself is called fear of positive evaluation. Fear of positive evaluation has been studied intensively in the context of social anxiety disorder (SAD). It is not known if individuals with borderline personality disorder (BPD) fear positive evaluation and which factors are associated with fear of positive evaluation in BPD. Methods: We applied the fear of positive evaluation scale and further self-report measures (e.g., social phobia inventory, rejection sensitivity questionnaire) to 36 patients with BPD, 29 patients with SAD and 35 healthy controls (HC). Results: A one-way ANOVA revealed that patients with BPD and patients with SAD reported significantly higher fear of positive evaluation than HC. Patients with BPD and SAD did not differ in their fear of positive evaluation. A hierarchical regression analysis revealed an association between rejection sensitivity and fear of positive evaluation in the BPD sample. However, this association disappeared when controlling for social anxiety. Conclusion: Our results indicate that individuals with BPD fear positive evaluation as much as individuals with SAD do, which has implications for clinical practice. Our results further imply that social anxiety is decisive for high fear of positive evaluation in patients with SAD and patients with BPD

Feeling excluded no matter what? Bias in the processing of social participation in borderline personality disorder

Background: Patients with Borderline Personality Disorder (BPD) feel ostracized even when they are included. This might be due to a biased processing of social participation in BPD. We examined whether patients with BPD also process social overinclusion in a biased manner, i.e., whether they feel ostracized even when the degree of social participation is increased. Methods: An EEG-compatible version of Cyberball was used to investigate the effects of inclusion and overinclusion (33% vs. 45% ball receipt) on perceived ostracism, need threat and P3 amplitude, an EEG indicator for expectancy violation. Twenty-nine patients with BPD, 28 patients with Social Anxiety Disorder (SAD) and 28 healthy controls (HC) participated. Results: The P3 amplitude was enhanced for patients with BPD and SAD compared to HCs independent of condition. Both patient groups reported more perceived ostracism relative to HCs in the inclusion but not in the overinclusion condition. Only patients with BPD reported stronger need threat in both conditions. Conclusions: The EEG results imply that being socially included violates the expectations of patients with BPD, irrespective of the actual degree of social participation. However, when overincluded, patients with BPD no longer feel ostracized. Except for need threat, patients with SAD might show a comparable bias in the processing of social participation as patients with BPD. Keywords: Borderline personality disorder, Social anxiety disorder, Social cognition, Social participation, Overinclusion, Event-related brain potential