Background: Previous studies have suggested increased sensitivity for emotional facial expressions and subtle impairments in emotion recognition from facial expressions in borderline personality disorder (BPD). It has been proposed that facial mimicry contributes to emotion recognition of and emotional response to facial expressions. This study investigated whether BPD patients differ in facial reactions, emotion recognition and their subjective emotional response to faces showing different emotional expressions. Method: Twenty-eight female BPD patients and 28 healthy controls underwent a facial recognition task with dynamic facial pictures while facial muscle activity (occipitofrontalis, corrugator supercilii, levator labii superioris, zygomaticus major and orbicularis oculi) was recorded. Furthermore, participants rated the emotional intensity of the presented faces and the intensity of their subjective feeling of this emotion. Results: Compared to controls, BPD patients showed enhanced responses of the corrugator supercilii muscle in response to angry, sad and disgusted facial expressions, and attenuated responses of the levator labii superioris in response to happy and surprised faces. There were no overall group differences regarding emotion recognition performance or intensity ratings. Conclusion: These results do not support the view that facial recognition in BPD is impaired or that there is a general hypersensitivity to the emotional state of others. Instead, they suggest a negativity bias in BPD, expressed by reduced facial responding to positive social signals and increased facial responding to negative social signals. This is a pattern of facial reactions that might contribute to the difficulties in social interactions frequently reported by patients with this disorder.

Background Aggressive behaviour is a prevalent and harmful phenomenon in patients with borderline personality disorder (BPD). However, no short-term, low-cost programme exists that specifically focuses on aggression. Aims Attuning therapy modules to pathogenetic mechanisms that underlie reactive aggression in BPD, we composed a 6 week mechanism-based anti-aggression psychotherapy (MAAP) approach for the group setting, which we tested against a non-specific supportive psychotherapy (NSSP). Method A cluster-randomised two-arm parallel-group phase II trial of N = 59 patients with BPD and overt aggressive behaviour was performed (German Registry for Clinical Trials, DRKS00009445). The primary outcome was the externally directed overt aggression score of the Modified Overt Aggression Scale (M-OAS) post-treatment (adjusted for pre-treatment overt aggression). Secondary outcomes were M-OAS irritability, M-OAS response rate and ecological momentary assessment of anger post-treatment and at 6 month follow-up, as well as M-OAS overt aggression score at follow-up. Results Although no significant difference in M-OAS overt aggression between treatments was found post-treatment (adjusted difference in mean 3.49 (95% CI −5.32 to 12.31, P = 0.22), the MAAP group showed a clinically relevant decrease in aggressive behaviour of 65% on average (versus 33% in the NSSP group), with particularly strong improvement among those with the highest baseline aggression. Most notably, significant differences in reduction in overt aggression between MAAP and NSSP were found at follow-up. Conclusions Patients with BPD and aggressive behaviour benefited from a short group psychotherapy, with improvements particularly visible at 6 month follow-up. Further studies are required to show whether these effects are specific to MAAP.

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