Authors Accepted Manuscript

Interaction Between Behavioral Inhibition and

Emotional Processing in Borderline Personality
Disorder Using a Pictorial Emotional Go/No-Go
Paradigm

Christopher Sinke, Axel M Wollmer, Jonas Kneer,

Kai G. Kahl, Tillmann H.C. Krger
www.elsevier.com/locate/psychres

PII: S0165-1781(17)30128-2
DOI: http://dx.doi.org/10.1016/j.psychres.2017.06.046
Reference: PSY10593
To appear in: Psychiatry Research
Received date: 23 January 2017
Revised date: 13 April 2017
Accepted date: 8 June 2017
Cite this article as: Christopher Sinke, Axel M Wollmer, Jonas Kneer, Kai G.
Kahl and Tillmann H.C. Krger, Interaction Between Behavioral Inhibition and
Emotional Processing in Borderline Personality Disorder Using a Pictorial
Emotional Go/No-Go Paradigm, Psychiatry Research,
http://dx.doi.org/10.1016/j.psychres.2017.06.046
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 Interaction Between Behavioral Inhibition and Emotional Processing in Borderline

Personality Disorder Using a Pictorial Emotional Go/No-Go Paradigm

Christopher Sinkea, Axel M Wollmerb, Jonas Kneera, Kai G. Kahla, Tillmann H. C. Krgera
a
Department for Psychiatry, Social Psychiatry and Psychotherapy, Medical School

Hannover, Germany
b
Clinics for Gerontopsychiatry, Asklepios Clinics Nord Ochsenzoll,

Hamburg, Germany

*
Corresponding author. Tillmann H.C. Krger, Medical School Hannover, Carl-Neuberg-
Strae 1, 30625 Hannover. Krueger.tillmann@mh-hannover.de

Abstract

Borderline personality disorder (BPD) is characterized by difficulties in emotional regulation

and impulse control. In this study, we presented a novel picture-based emotional go/no-go

task with distracting emotional faces in the background, which was administered to 16

patients with BPD and 16 age-matched healthy controls. The faces displayed different

emotional content (angry, neutral, or happy). Results showed differences in sensitivity

between patients and the control group, with patients exhibiting less sensitivity in the task,

and also showed influences of emotional content represented in the distracting faces in both

groups. Specifically, happy faces decreased sensitivity compared to angry faces. It seemed as

though processing of a positive emotional stimulus led to a more relaxed state and thereby to

decreased sensitivity, while a negative emotional stimulus induced more alertness and

tension, leading to higher sensitivity. Thus, this paradigm is suitable to investigate the

interplay between emotion processing and impulse control in patients with BPD.
 Introduction

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.;

DSM5; (American Psychiatric Association, 2013), borderline personality disorder (BPD) is

characterized by a pervasive pattern of instability of interpersonal relationships, self-image,

and affects, and marked impulsivity, beginning in early adulthood and present in a variety of

contexts (DSM-5; p.663). Difficulties in emotional regulation and impulse control are core

features of BPD (Lieb et al., 2004; Glenn and Klonsky, 2009; Sebastian et al., 2013).

Differences are not only found in regulation of emotion but also in basic processing of

emotions. For example, patients with BPD show a bias toward negative emotions, especially

anger ( Wagner and Linehan, 1999; Domes et al., 2009), as well as a lower detection

threshold for negative facial expressions (Lynch et al., 2006). These observations might be

neurobiologically linked to the findings that the processing of negative emotions involves

higher activation of the amygdala ( Herpertz et al., 2001; Donegan et al., 2003) and a

diminished functional connectivity between frontal and limbic brain areas (New et al., 2007;

Silbersweig et al., 2007). It is possible that an elevated activation through negative emotions

can lead to problems in regulating these emotions.

High levels of impulsivity are often observed clinically and are part of the diagnostic

criteria in the DSM-5. Nevertheless, experimental investigations employing typical tasks

related to impulsivity (e.g., go/no-go or Stroop tasks) showed mixed results (Sebastian et al.,

2013). These authors speculated that clinically observed impulsivity is related to the

regulation of emotions, meaning that impulsivity depends on emotional processing. This

would mean that the higher activity as a result of processing of negative emotions is related to

a worse inhibitory control. The interaction of behavioral inhibition and emotional processing

is not well investigated in patients with BPD. Only Silbersweig et al. (Silbersweig et al.,

2007) employed an emotional go/no-go paradigm in patients with BPD, with emotional
words and the font as decision criterion. They did not find strong behavioral effects

separating the control group from BPD patients. Patients only showed higher omission errors

with negative words but not more commission errors. Others have employed a letter-based

go/no-go task after emotion induction but without a behavioral effect (Jacob et al., 2013).

Extracting the emotional content of words involves many steps involving at least word

recognition and comprehension. As not every word has an emotional load, words have to be

judged on their emotional content. Thus, the connection between words and emotions is

rather indirect: a possible explanation for weak experimental results.

Therefore, we intended to develop a paradigm with a more direct emotional

manipulation of inhibitory behavior. The human brain is highly specialized in interpreting

facial expressions; even infants as small as four months are able to differentiate facial

expression of familiar faces (Walker-Andrews et al., 2011). As social beings it is important

for survival to quickly judge the emotional state of other people to know if they are a

potential threat or not. Face processing is implemented very early (established within the first

month) while letter processing is learned at a higher age (typically between five and seven

years), by reusing cortical areas in the parietal-occipital junction (Dehaene and Cohen, 2007)

which processed other data before learning how to read. Also, emotional faces evoke

enhanced neuronal processing compared to other stimuli (Palermo and Rhodes, 2007). Not

surprisingly, it was shown that letters and faces are processed differently in the context of a

go/no-go task, and facial expressions compared to words better tapped emotional processing

circuits (Shafritz et al., 2006) since single letters have no emotional content. Thus, faces

directly tap emotional processing circuits and seem to be more suitable for emotion

modulation.

For the current investigation we were specifically interested in the interaction between

inhibitory behavior and emotional processing. Based on the clinical impression of BPS we
test the idea that emotional processing and especially processing of negative emotions lead to

a worse inhibitory control in patients with BPS. Therefore participants completed a visual

go/no-go task using geometrical signs with emotional faces in the background. We expected

more difficulties in behavioral inhibition in patients with BPD and an influence of facial

emotional expression on task performance in both groups. We also hypothesized that due to

higher amygdala activity for negative emotions (Donegan et al., 2003) the influence of

negative emotional context should be greater in patients with BPD.

Methods

Participants

Sixteen participants who were diagnosed with BPD according to SCID-II interviews

(15 female, 1 male; age 28.9 8.3 years) and 16 age-matched healthy controls not diagnosed

with BPD (control group; 15 female, 1 male; age 33.9 13.8 years; T(24.53) = 1.245, p =

.225, unequal variance) participated in the study. Patients were recruited from a ward

specialized in the treatment of BPD at Hannover Medical School (BSL-23: 2.000.7) and

most had a concomitant depression symptoms (BDI: 31.213.5). The study was approved by

the local ethics committee and conducted in accordance with the Declaration of Helsinki.

Experimental Paradigm

Participants performed a go/no-go task where they were instructed to react to

geometrical figures as fast as possible. In the background, faces with different emotional

expressions (positive, neutral, or negative) were shown. In the training sessions only go trials

were presented, while in the main experiment 70% of the trials were go and 30% were no-go

trials.
Stimuli

Faces from the NimStim database were used (Tottenham et al., 2009). The pictures

span a visual angle of 6.6 X 9. The geometrical figures consisted of a black circle as a go

signal and a black square as a no-go signal. These figures had a visual angle of 0.5 and were

placed at fixed coordinates around the nose region. In the training session, 20 closed facial

expressions were used, while in the main experiment open facial expressions were shown.

Open expression were used in the main experiment because these expressions display

emotions that are easily recognizable and less subject to interpretation, especially in the

neutral condition. For the main experiment, 15 males and 15 females from each group were

administered 30 facial expressions of each of the following emotions: neutral, angry, and

happy. Each face was presented five times. The presentation of the visual stimuli and the

recording of behavioral data was performed using Presentation software

(www.neurobs.com) on a Lenovo Yoga ThinkPad with a 12.5 monitor.

Experimental Procedure

After verbal instruction and signing of the consent form, the experiment started with a

training session consisting of 20 go trials to familiarize the participants with the task. The

main experiment consisted of 450 trials, with 150 for each condition. Each condition

consisted of 105 go trials and 45 no-go trials. Trials were presented in randomized order with

the limitation that a no-go trial would be followed by at least one go trial. Pictures and

geometrical figures for a single trial were presented for 2 seconds as described by Brown et al

(Brown et al., 2012), and were then followed by a variable inter-stimulus interval (ISI)

between 400 and 800 milliseconds. During the ISI, a fixation cross was presented. The

overall experiment lasted around 21 minutes.

Analysis

All behavioral data analyses were conducted using SPSS version 18.0. Dependent

variables were correct go responses and the corresponding reaction time and incorrect no-go

responses. Here the reaction time was not analyzed as participants made very few mistakes,

often even no mistakes at all. Results with a p < .05 were considered statistically significant.

All statistical analyses were performed using two-tailed testing. Reported numbers indicate

mean value (M) standard deviation (SD) unless otherwise stated. As all dependent variables

were normally distributed (tested using the Kolmogorov Smirnov test), parametric tests were

used throughout. Sensitivity was analyzed using d (MacMillan, 2002). This statistic was

calculated using z-transformed correct go responses (hit rate) and subtracting z-transformed

incorrect no-go (false alarm rate) responses. For calculation purposes a value of 0 was treated

as 0.01 and a value of 1 was treated as 0.99. We decided to use d instead of commission

errors as here behavioral inhibition is operationalized independent of the individual strategy.

Additionally, a 2 x 3 repeated measure analysis of variance (rmANOVA) was conducted with

the between-subject factor titled borderline (patients/controls) and the within-subject factor

titled emotional expression (negative/neutral/positive).

Results

We found that sensitivity values were lower in borderline patients than healthy volunteers

and that sensitivity values were greatest for angry faces and least for happy faces (Figure 1).

However, borderline patients did not show a different pattern of sensitivity to these emotional

faces than healthy volunteers. The findings were confirmed by repeated measures ANOVA

with a main effect for borderline vs healthy (F (1, 30) = 4.392, p = .045, partial 2 = .128) and

a main effect for emotional expression (F (2, 60) = 5.427, p = .007, partial 2 = .153) but no

interaction effects (F (2, 60) = 1.085, p = .34). A post-hoc t-test showed a difference between
angry and happy faces (T(31) = 3.685, p= .001) and a trend towards significance for the

comparison between neutral and happy faces (T (31) = 1.906, p = .066).

We found slower reaction times to go signs in borderline patients, but no influence on

reaction times for the different emotional faces nor a different behavior for the two groups for

the different faces (Figure 1). This finding is confirmed by a rmANOVA with a main effect

for borderline vs healthy controls (F (1, 30) = 13.329, p = .001, partial 2 = .308) but no effect

for emotional expression (F (2, 60) = 0.458, p = .64), nor an interaction effect (F (2,60) =

0.664, p = .519). Post-hoc t-tests showed that patients with BPD reacted slower to a go sign

compared to those in the control group (T (30) = 3.651, p = .001).

[INSERT FIGURE 1 HERE]

Discussion

In the present study, a pictorial go/no-go task with distracting emotional faces in the

background was developed to test for the interaction of emotional processing and behavioral

inhibition in patients with BPD and age-matched patients without a diagnosis of BPD

(control group). BPD patients showed a decreased sensitivity and a slower reaction time in go

responses compared to the control group. Angry faces induced higher sensitivity in both

groups compared to happy faces. Hence, this paradigm was able to detangle effects of

emotional valence as well as BPD on a behavioral task.

At first glance, elevated sensitivity and lack of increased error rates while watching angry

faces seems counterintuitive. However, the response pattern may point to the immediate

relevance of the respective emotional stimuli with happy faces signaling a secure situation

and angry faces as a possibly threatening situation. This in turn may lead to a relatively
relaxed state in the individual and to consecutive lower attention and sensitivity levels, while

angry or neutral faces (which may be perceived as ambiguous) increase attentional effort.

Participants with BPD had significantly lower sensitivity levels as well as higher

reaction times in go trials irrespective of emotional content compared to controls. This may

indicate that the current pictorial go/no-go paradigm is more suitable in inducing behaviorally

relevant emotions compared to previously used paradigms with a word- or letter-based

approach (Goldstein et al., 2007; Silbersweig et al., 2007 ; Perez et al., 2016). This again

underlines the biological relevance of social signals via facial expressions in signaling

affective states (Ekman and Friesen, 1969). Decreased sensitivity levels and increased

reaction time in BPD patients can be interpreted in different ways. BPD psychopathology

might generally induce higher distraction and longer processing times through facial

emotional expressions, since individuals diagnosed with BPD may have more difficulties in

assessing and interpreting social signals in an efficient way and may tend toward negatively

biased judgements. Limiting further interpretation of results was the fact that we did not

assess the subjective emotional perception of respective stimuli. An alternative explanation of

differences between BPD patients and controls may derive from diminished levels of

cognitive functioning (such as attention or working memory) caused by the disease itself.

In contrast to our initial hypothesis there was no interaction between emotional

expression and group allocation, meaning that negative or positive facial emotions did not

influence impulsivity in BPD patients in a different way or to a higher degree compared to

controls. Imaging studies have shown that processing of happy faces also involves amygdala

activity ( Somerville et al., 2004; Juruena et al., 2010), and that BPD patients have elevated

levels of amygdala activity even when processing neutral facial stimuli (Donegan et al.,

2003). Thus, it is possible that amygdala response is higher in all face conditions and not only

during processing of negative emotional content, leading to a general decreased

sensitivity/higher impulsivity in patients. Additionally, a diminished communication between

limbic and frontal areas of the brain could then lead to less activity in the frontal cortex

resulting in higher impulsivity/reduced sensitivity during emotional processing.

Limitations

This study was mainly conducted on female subjects. As the clinical picture of male and

female patients with borderline personality disorder differs it is of interest to explore whether

impulse control in male patients with BPS is similarly affected by emotional content. In

addition the sample size of the present study is quite low and warrants evaluating the

paradigm a in a larger sample with equal numbers of male and female subjects in order to

account for the factor gender. Also, in this initial study we did not control for possible

confounding factors like depression or working memory. As the literature does not suggest

that depression or working memory has a substantial impact on go-nogo performance

(depression: (Ladouceur et al., 2006; Wessa et al., 2007; Ruchsow et al., 2008); working

memory: (Hagenhoff et al., 2013) it is unlikely that the described effects are driven by these

factors.

Clinical implications

The paradigm explained here was primary developed for research purposes and for better

understanding of BPS pathology. Therefore immediate clinical implications are rather small

at present. However, if the connection between impulsivity and emotional processing turns

out to be indicative for patients with BPS only, it could be an additional tool for diagnostic

purposes. Furthermore this connection opens the possibility for the refinement of treatment

approaches. For example downregulation of emotional processing could then lead to a better

impulse control and changes could be detected by this novel paradigm/test.

 Declaration of interest

This research did not receive any specific grant from funding agencies in the public,

commercial, or not-for-profit sectors.

Acknowledgements

Development of the MacBrain Face Stimulus Set was overseen by Nim Tottenham and

supported by the John D. and Catherine T. MacArthur Foundation Research Network on

Early Experience and Brain Development. Please contact Nim Tottenham at

tott0006@tc.umn.edu for more information concerning the stimulus set.

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Figure 1: A) Sensitivity: The sensitivity in relation to the emotional expression in the

background (M SEM) is plotted here. Emotional expression influences sensitivity in

the go/no-go task with reduced sensitivity to happy faces. Also, patients with BPD

show a reduced sensitivity compared to healthy controls independent of the emotional

background. B) RT in go trials: Plotted is the reaction time (RT) for go trials in

relation to the facial expression in the background (M STD). Patients with BPD

react slower compared to controls independent of the emotional expression.

Highlights

A visual emotional go-nogo task is presented using distracting emotional faces in the
background
Patients with borderline-personality disorder show decreased sensitivity and slower RT
Positive emotions in the background decrease sensitivity independent of group