Differential effects of the menstrual cycle on reactive and proactive aggression in borderline personality disorder

Abstract

Borderline personality disorder (BPD) is characterized by rapidly shifting symptoms, including intense anger and aggressive behavior. Understanding how fluctuations in ovarian hormones across the menstrual cycle may contribute to symptom instability is key for accurate assessment of BPD symptoms and effective interventions. Reactive and proactive aggression, as well as anger in and out, were assessed daily in 15 physically healthy, unmedicated naturally cycling female individuals without dysmenorrhea meeting criteria for BPD across 35 days. Urine LH surge and salivary progesterone were used to confirm ovulation and verify cycle phase. Cyclical worsening of symptoms was evaluated using multilevel models to evaluate symptom differences between cycle phases. Both forms of aggressive behavior demonstrated marked cycle effects, with reactive aggression highest during perimenstrual cycle phases, co-occurring with increases in anger in and out. In contrast, highest levels of proactive aggression were observed during the follicular and ovulatory phases, when emotional symptoms and anger were otherwise at lowest levels. These findings highlight the importance of identifying the function of aggression when considering potential psychological and biological influences. Naturally cycling individuals with BPD may be at elevated risk for perimenstrual worsening of a range of interpersonally reactive symptoms, including reactive aggression, whereas proactive aggression may occur more in phases characterized by less emotional and cognitive vulnerability and greater reward sensitivity. Research on aggression in this population should consider cycle effects. Cycling individuals with BPD attempting to reduce aggressive behavior may benefit from cycle-tracking to increase awareness of these effects and to develop appropriate strategies.

Psychiatric Symptoms Across the Menstrual Cycle in Adult Women: A Comprehensive Review

“… 167 In this same sample, anger/irritability was highest in the perimenstrual phase, with reactive aggression highest in the mid-luteal phase and proactive aggression highest during ovulation and lowest perimenstrually. 168 …”

Menstrual Cycle in Trauma-Related Disorders: A Mini-Review

“…Specifically, two studies revealed a link between cyclical menstrual changes and BPD-like features in non-clinical samples ( 6 , 21 ). Two studies demonstrated menstrual cycle-related changes in BPD symptoms in unmedicated women with regular menstrual cycles in clinical samples ( 24 , 54 ). Considering these four studies, it appears that individuals with BPD had a clear pattern of perimenstrual (i.e., late luteal phase to day 3 of menses) exacerbation, with symptoms of irritability and anger appearing in the luteal phase and peaking in the perimenstrual phase.…”

Cold-Blooded and on Purpose: A Review of the Biology of Proactive Aggression

“…One study to date has evaluated the relationship of PA and female sex-specific hormones ( Table 2 ). Peters and coauthors [ 74 ] quantified PA and the ovulatory hormones estradiol and progesterone in a small sample ( n = 15) of naturally cycling women with BPD. PA, measured using the RPQ, was highest during the follicular and ovulatory cycle phases, where progesterone was lowest.…”