Emotions and memory in borderline personality disorder.

Review Psychopathology 2014;47:71–85 DOI: 10.1159/000356360

Received: March 6, 2013 Accepted after revision: October 6, 2013 Published online: December 13, 2013

Emotions and Memory in Borderline Personality Disorder Dorina Winter a Bernet Elzinga b Christian Schmahl a a

Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany; b Department of Clinical Health and Neuropsychology, Leiden University, Leiden, The Netherlands

Key Words Borderline personality disorder · Memory · Learning · Emotion · Mood

impair learning and memory independently of stimulus valence. This review discusses methodological challenges of studies on memory and emotions in BPD and makes suggestions for future research and clinical implications.

Abstract Memory processes such as encoding, storage, and retrieval of information are influenced by emotional content. Because patients with borderline personality disorder (BPD) are particularly susceptible to emotional information, it is relevant to understand whether such memory processes are altered in this patient group. This systematic literature review collects current evidence on this issue. Research suggests that emotional information interferes more strongly with information processing and learning in BPD patients than in healthy controls. In general, BPD patients do not seem to differ from healthy control subjects in their ability to memorize emotional information, but they tend to have specific difficulties forgetting negative information. Also, BPD patients seem to recall autobiographical, particularly negative events with stronger arousal than healthy controls, while BPD patients also show specific temporo-prefrontal alterations in neural correlates. No substantial evidence was found that the current affective state influences learning and memory in BPD patients any differently than in healthy control subjects. In general, a depressive mood seems to both deteriorate and negatively bias information processing and memories, while there is evidence that dissociative symptoms

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Borderline personality disorder (BPD) is a serious mental condition which the DSM-IV-TR includes among the axis II personality disorders in cluster B (dramatic) disorders [1]. Recent epidemiological data estimates the BPD lifetime prevalence to be 1–6%, while most epidemiological studies reckon a prevalence closer to 1% of the population, with no significant gender differences [2–4]. BPD is characterized by instability of affective regulation and self-image, by impulsivity, interpersonal disturbance [5], repeated self-injurious behavior, and chronic suicidal tendencies [5, 6], even though the clinical presentation of BPD is heterogeneous. Affective dysregulation is considered a core feature of BPD [7–9]. The most prominent model for affective dysregulation in BPD is based on the theory of Linehan and Kehrer [10]. This model assumes that BPD patients suffer from elevated affective vulnerability and a heightened sensitivity to aversive emotional stimuli [11–13], intense and longer affective reactions [11, 14], and a slow return to baseline affective arousal [15, 16]. A current model concerned with the neural basis of this affective dysregulation is the frontoDorina Winter Central Institute of Mental Health Department of Psychosomatic Medicine and Psychotherapy PO Box 12 21 20, DE–68072 Mannheim (Germany) E-Mail dorina.winter @ zi-mannheim.de

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© 2013 S. Karger AG, Basel

The individual: personality, affective state, experiences, psychopathology Working memory: attention and elaboration

Long-term memory: (re)consolidation and retrieval Consolidation

Emotional stimulus

Declarative memory

Skill learning Priming Classical conditioning Habituation

Semantic memory (facts) Autobiographical memory (events)

Encoding

Nonemotional stimulus

Nondeclarative memory

Nonemotional stimulus

Fig. 1. Emotional stimuli and memory systems. Simplified mod-

el of the processing of emotional stimuli in the relevant memory systems. Memory processes are imbedded in individual processing

biases originating from personality, current affective state, personal experiences, or psychopathology. Adapted from Hamann [33] and Tulving [34].

limbic inhibition model [17]. This model assumes diminished control of prefrontal structures over hyperactive limbic structures in BPD. More precisely, BPD patients manifest hyperreactivity of the amygdala [18–21, but see 22] and impaired inhibition through the dorsolateral, medial, and orbital prefrontal cortex (PFC) [20, 23–26] as well as the anterior cingulate cortex (ACC) [20, 27, 28]. All in all, individuals with BPD show an extraordinarily strong response to emotional stimuli, likely linked to brain processes of fronto-limbic disinhibition. As emotion processing and fronto-limbic structures are known to be associated with learning and memory [29–31], BPD patients’ affective dysregulation may coincide with abnormal memory processes. Actually, this issue already concerned researchers in the 1930s, when Stern [32] argued that borderline patients may lack integrated autobiographical memories of their attachment figure, which were supposed to help self-regulate children’s affect. Today, cognitive psychology and neuroscience provide a comprehensive framework for understanding emotions and memory in BPD. Figure 1 summarizes the relevant

memory processes. Two processes that are involved in memory processing of emotional content need to be considered [33]: first, emotional content captures more attention and induces deeper elaboration than nonemotional content. This means that emotional information may also be distracting when nonemotional information needs encoding. If BPD patients are more sensitive to emotional information, emotional information may distract them more easily from remembering less emotional information. Second, if information is elaborated more deeply, it is more likely transferred into long-term memory and thus consolidated better, allowing easier recall. This may affect any memory system: both nondeclarative memory – which implicitly stores information such as skills in procedural memory and includes processes such as priming and habituation – and also declarative memory – which stores information on facts in semantic memory and events in episodic or autobiographical memory [34]. Accordingly, BPD patients might remember emotional information better than nonemotional information. Because BPD patients have often experienced extremely emotional situa-

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Psychopathology 2014;47:71–85 DOI: 10.1159/000356360

Winter/Elzinga/Schmahl


Emotional stimulus

Systematic Literature Review

A systematic review of the literature was performed in November 2012 using the databases PubMed, PsycINFO, and PSYNDEX. We searched for the terms ‘borderline personality disorder’, ‘memory’ or ‘learning’, and ‘emotion’, ‘mood’, or ‘affective state’. This resulted in 152 hits in PubMed, 50 hits in PsycINFO, and 29 hits in PSYNDEX. We selected experimental studies with BPD patient samples. Studies were included when they obtained BPD diagnoses with a structured clinical interview. The article language needed to be English. There were no other criteria for studies to be included in this review. A total of 34 studies which met the inclusion criteria were identified. Then, we screened the references of relevant original publications for relevant additional studies meeting the inclusion criteria, leading to the inclusion of 46 studies in total (a tabular summary of the studies included and their major findings is shown in the online suppl. table, see www.karger.com/doi/10.1159/000356360). In order to summarize the findings, we decided to categorize the studies by the processes involved, delineating: first, studies targeting BPD patients’ ability to cognitively control attention to target information while being distracted by emotional stimuli; second, studies focusing on patients’ ability to remember or forget emotional information, including classical conditioning, habituation, and list learning; third, as a substantial amount of studies covered BPD patients’ autobiographical memories, we decided to review the corresponding studies separately, and fourth and finally, studies on the relationship between affective state such as mood or dissociative symptoms and BPD patients’ memory performance. We will review the selected studies by category. The paradigms Emotions and Memory in BPD

used are manifold and the studies using similar paradigms used heterogeneous methodologies. Accordingly, we decided to concentrate on a qualitative, rather than a quantitative account for this review.

Exaggerated Memory Interference by Emotional Stimuli?

As BPD patients are considered to be more sensitive to emotional information than healthy controls, they may show increased attention to emotional information, and as a result a reduced ability to inhibit the processing of irrelevant emotional stimuli while processing relevant information. For example, when patients are distracted by emotional stimuli during encoding, this could lead to reduced encoding and storage of more neutral target information [33, 40–42] and thus altered memory processes. The different paradigms that have been used to shed light on this issue are summarized below. Emotional Stroop Task Most studies investigating distractibility by emotional information in BPD used the emotional Stroop task. In this paradigm, subjects have to characterize a visual target word, for example: name the color of neutral or emotional words. Interference is thought to be reflected by prolonged reaction times in the judgement of emotional versus neutral words. BPD patients showed a stronger interference effect than healthy controls, especially for negative words [43, 44], for words related to BPD schemata [43, 44], and for personally relevant negative words [45]. One study even showed stronger interference in BPD patients for positive words as well [44]. BPD schema-unrelated words or personally irrelevant words produced this effect only in some [44], but not in all studies [45, 46]. Interestingly, prolonged reaction times after emotional versus neutral stimuli had disappeared in recovered BPD patients after 3 years of psychotherapy, which was not the case for unrecovered BPD patients [47]. This supports the idea that, with psychotherapy, interference by emotional stimuli can decrease, which suggests that emotional interference is indeed a characteristic but alterable feature of BPD symptomatology. Also, the reaction times of BPD patients were only slower for emotional words if the words were presented supraliminally, but not under subliminal conditions [44], suggesting that higher cortical processes are involved. It needs to be mentioned that the current relevance of stimulus material for the study participants as well as comorbid Psychopathology 2014;47:71–85 DOI: 10.1159/000356360

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tions such as abuse or maltreatment [35–37], they may also have more intense emotional autobiographical memories to process. Finally, it needs to be considered that the individual’s current affective states alter the patients’ ability to remember emotional information. Specifically, individuals can encode or recall information more easily if the valence is congruent with the individual’s mood [38, 39]. So, the extreme affective states of BPD patients may also bias encoding and recall of emotional information. In order to review evidence regarding these hypotheses, we conducted a systematic, qualitative literature review. This article presents its methodology and the collected evidence. Then, it discusses methodological challenges, suggestions for future research, and clinical implications.

Negative Priming In a negative priming paradigm, a stimulus first needs to be ignored and then becomes a target, which leads to reactions that are slower or more error prone. In such a 74


negative priming paradigm, no difference was found between BPD patients and healthy controls regarding the ability to inhibit negative information, even though BPD patients showed a trend towards reduced inhibition in response to negative words [46]. Thus, negative priming does not support the hypothesis that in BPD patients memory encoding is extraordinarily disturbed by emotional information. Emotional Working Memory Tasks In a verbal (Sternberg) working memory paradigm where emotional International Affective Pictures System (IAPS) pictures are presented as distractors, BPD patients reacted more slowly and less correctly than healthy controls [52]. Also, patients exhibited enhanced neuronal activity in the amygdala, insula, and ACC during the working memory task, especially after negative distracting stimuli. Similarly, a study presenting an n-back task – while emotional IAPS were presented in the background – to male patients with antisocial personality disorder as well as BPD found delayed responses during the presentation of emotional pictures and enhanced amygdala activity in patients more than in control participants [53]. Thus, this suggests that emotional interference diminishes working memory performance. List Learning Paradigms In a visual list learning task using pictures from the IAPS as emotional distractors, BPD patients and healthy controls did not differ significantly in mean recall performance [54]. The same was true for list learning with interference by an emotional picture from the Thematic Apperception Test [49]. In contrast, for auditory verbal stimuli, BPD patients showed worse memory for word lists if distracting negative words were presented, in comparison to control participants [55]. Another behavioral study in BPD patients and healthy controls combined a list learning memory task with a masking paradigm. In masking paradigms, irrelevant information is supposed to diminish information before and after emotional stimuli. This study measured the recall of target items presented in a list before and after an emotional picture [56]. Here, negative emotional items presented before as well as after the target item diminished the memory of target items in BPD patients more than in comparable control participants. Overall, evidence from declarative memory paradigms strongly supports the notion that, here, emotional information substantially interferes with memory performance in BPD. Winter/Elzinga/Schmahl


posttraumatic stress disorder (PTSD) was found to contribute to a possible negative bias in the emotional Stroop task [45]. Thus, further studies on the emotional Stroop task need to consider possible moderating variables. However, a significant number of studies did not find reaction time differences in the emotional Stroop task to be different in BPD patients versus healthy controls [46, 48, 49; only a statistical trend in 50]. The articles mentioned above discuss a number of possible explanations for this heterogeneity. Domes et al. [46] argue that comorbid axis I symptomatology, such as anxiety or PTSD, may have contributed to the emotional Stroop effect in other studies. On the other hand, they also discuss that slower overall reaction times in BPD patients may have leveled out a possible Stroop effect in other studies. Wingenfeld et al. [50] point out that their version of the emotional Stroop task may not have been able to induce measureable effects as they used button presses instead of vocal responses to characterize target words. Minzenberg et al. [48] similarly assume that their task version was also not well established. Another approach to emotional interference during encoding in BPD used the emotional Stroop task during neuroimaging. One functional magnetic resonance imaging (fMRI) study found that BPD patients did not show any activation in relevant brain regions such as the ACC and PFC during the emotional Stroop task compared to healthy control subjects [50]. Another fMRI study with an adapted Stroop task revealed neural differences in BPD patients compared to healthy control subjects in terms of decreased medial orbitofrontal and subgenual anterior cingulate activity and increased activity in the insula, dorsal ACC, and lateral orbitofrontal areas [51]. Thus, both studies found reduced activation in regions associated with attentional and emotional control. The second study also reported increased activation in regions associated with emotional reactivity. Accordingly, these findings were interpreted as neural correlates of emotional dysregulation in BPD. Taken together, behavioral studies using the emotional Stroop task provided heterogeneous evidence with regard to the question of whether BPD patients show heightened interference by negative stimuli. Neuroimaging data rather supports this assumption. However, comorbidities may have contributed to this effect.

Memorizing Emotional Information: From Learning to Forgetting

Emotional material may be learned and memorized differently in BPD. And it important for understanding the maintenance of psychological disorders whether irrelevant or burdensome memories can be selectively forgotten. Studies regarding memory of emotional stimuli used paradigms targeting nondeclarative memory in paradigms of affective conditioning and habituation, as well as declarative memory processes such as short deliberate memorization or forgetting of lists of words or remembering autobiographical memories. Affective Conditioning It is well known that the amygdala has a central role in the formation and storage of memories associated with emotional events in general, and fear in particular, as in conditional fear learning paradigms [57–63]. Because BPD patients manifest alterations in amygdala activity, they may also show altered fear conditioning. This was investigated using differential delay conditioning in subjects with BPD [64, 65]. In the acquisition phase, healthy subjects responded to presentation of the conditioned stimulus with an increase in arousal and skin conductance, but with a decrease in valence ratings. In the extinction phase, the physiological responses returned to baseline. The same pattern was generally shown by subjects with BPD, but only if they had low levels of dissociative symptoms [64] and did not have PTSD [65]. These results suggest that patients with BPD are more likely to show alterations in differential aversive conditioning, although impaired differential affective conditioning does not appear to be a general attribute of BPD but rather is related to co-occurring pathological conditions. Emotions and Memory in BPD

Habituation So far, two fMRI studies have focused experimentally on habituation in BPD. In the first study, negative, neutral, and positive pictures were repeatedly presented to patients with BPD, patients with schizotypal personality disorder, and healthy controls during fMRI [66]. BPD patients, but not the other two groups, revealed heightened amygdala activity in response to repeated emotional stimuli. In the second study, classical conditioning was used in BPD patients and healthy controls to pair visual cues with heat pain stimuli or no aversive stimulus [67]. Afterwards, the visual cues were presented repeatedly without the aversive stimulus during fMRI scanning. In response to the conditioned stimulus compared to the safety stimulus, the skin conductance response of BPD patients did not decrease over time in comparison to the safety stimulus, whereas the skin conductance of healthy controls did decrease. Also, in contrast to healthy controls, BPD patients did not respond to the conditioned cue versus the safety cue with a decrease in amygdala activity or an increase in ventromedial PFC activity over time. Furthermore, BPD patients showed increased connectivity of the amygdala with ventromedial PFC as well as decreased connectivity of subgenual ACC with dorsal ACC. These studies provide evidence for basic memory processes being altered in BPD, namely a deficient habituation to emotional stimuli. List Learning The earliest study on emotional list learning in BPD used negative, positive, ambivalent, and neutral words [68] to be learned and remembered afterwards. BPD patients with major depressive disorder (MDD) remembered fewer words than did healthy controls. However, similarly to control participants, they recalled positive words better than negative words. Patients with only MDD did not show this valence difference. In a delayed recognition task, BPD patients who also had MDD performed worse than the other two groups, again without displaying any particular valence effect. However, a limitation of the study is the lack of a patient group with BPD only. This group was present in a second study, in which BPD patients and healthy controls had to remember a list of positive, neutral, and borderline-specific words [69], where no differences were found between subjects with and without BPD. Finally, the third study had subjects with BPD and controls remember a list of positive, negative, or neutral words [46]. Again, no group differences were found in word recall. Also, no differences were found when BPD patients and control subjects had to rePsychopathology 2014;47:71–85 DOI: 10.1159/000356360

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Summary Taken together, the evidence suggests that BPD patients’ information processing is more easily disrupted by concurrently presented negative stimuli than the information processing of healthy controls. A substantial number of studies could show that this goes hand in hand with the worse memory of neutral target information processed in the context of the emotional Stroop task, working memory tasks, or in declarative memory paradigms. Still, the question remains whether BPD patients’ memory performance regarding target emotional words is also altered without any distraction. This will be discussed in the following section.

Directed Forgetting The directed forgetting paradigm is frequently used to study the impact of emotional material on encoding and retrieval of words [71]. In this paradigm, participants are instructed to remember or to forget lists of emotional or neutral words, respectively [72]. Usually, participants remember more items from the list to be remembered than from the list to be forgotten. With this paradigm, BPD patients and healthy controls were studied with lists of neutral, positive, and borderline-specific negative words [69]. Patients differed from healthy controls only when they had to forget borderline-specific words. They remembered more of these words. A better performance for to-be-remembered words only was found in another sample of BPD patients with abuse history, but differences in emotional valence could not be analyzed as they used too few stimuli per valence category [73]. In a third sample, BPD patients remembered more aversive words that were instructed to be forgotten [46]. Thus, findings were very heterogeneous, with a tendency for BPD patients to be less able to forget aversive or personally relevant information. Summary Nondeclarative memory of negative information may be biased in BPD in terms of slower habituation. On this topic, however, evidence is sparse. In contrast, declarative memory for emotional stimuli does not seem to be altered in BPD even though patients tend to display a reduced ability to forget aversive information.

Autobiographical Memory: Remembering Emotional Events

Autobiographical memories are memories of one’s personal life [74]. Emotional autobiographical memories are particularly well remembered [30, 75–77], likely facilitated by interplay of the prefrontal, amygdala, and medial temporal lobe regions [78, 79]. BPD patients have often experienced particularly aversive events, such as physical and sexual childhood abuse [80–82], which may lead to intense autobiographical memories. Also, as BPD patients show heightened emotional reactivity and en76


hanced amygdala reactivity, autobiographical memories of emotional events may be qualitatively different in individuals with and without BPD. The studies investigating this topic encompass overgeneral autobiographical memories, early childhood memories, neural correlates of negative life events, and recent autobiographical memories. Overgeneral Memories The usual test for investigating autobiographical memories is the Autobiographical Memory Test (AMT) [83]. In this test, participants need to describe autobiographical events that they associate with presented positive, negative, and sometimes neutral cue words. The main measure is the specificity of the recalled event. A memory is rated as ‘specific’ if it refers to an occasion or an event that can be located in time and place. The AMT was initially developed to study autobiographical memory in depression, finding that depressed patients remember fewer specific events [84–86]. Although some studies also found this effect when BPD patients were compared to healthy controls [87–89], most did not [90–92]. Some studies suggest that overgeneral memories in BPD patients are mainly due to comorbid depression [90, 91, 93]. Kremers et al. [94] compared memory specificity in the AMT of BPD patients with and without depression, patients with only depression, and healthy controls. Only BPD patients with comorbid depression recalled fewer specific memories than did controls. In one study, a negative correlation of overgeneral memories and parasuicidal acts was found for BPD patients [93]. Further, it was argued that group differences in cognitive variables such as intelligence quotient or education contribute to group differences in the specificity of recalled memories [88, 90]. Therefore, there appears to be no reliable evidence that patients with BPD recall more general memories than do controls. AMT test outcomes other than overgeneralization have rarely been reported in BPD: one study found equal latencies in memory recall and a more negative hedonic tone when compared to controls [92]. Early Childhood Memories In psychoanalytic tradition, the first studies of autobiographical memories of patients with BPD were interested in memories of very early childhood. BPD patients reported more negative first memories of their parents than neurotic and paranoid schizophrenic patients [95]. Also, BPD patients remembered their parents as being less caring and more controlling [96]. BPD patients reported more memories involving deliberate harm and Winter/Elzinga/Schmahl


member given or self-generated sentences [70] or events [49], regardless of stimulus valence. In conclusion, evidence suggests that BPD patients do not differ from control subjects with regard to verbal memory of emotional material.

Neurophysiological Correlates while Recalling Negative Life Events Several studies aimed to gain insight into the neural mechanisms underlying emotional autobiographical memories. As patients with BPD have often suffered from negative emotional experiences in their past, these studies focused on memories of negative personal experiences such as traumatic or unresolved life events [99–102] or memories of abandonment [103, 104]. For physiological measures, autobiographical auditory scripts were used to confront participants with their own idiographical traumatic experiences, as well as standard unpleasant (survival threat, rejection, and abandonment), neutral, and pleasant events. BPD patients responded with a higher autonomous response to idiographical traumatic and rejection/abandonment scripts than did healthy controls, with a co-occurring more negative subjective emotional condition [105]. In order to study the neural activity during the recall of traumatic events, Schmahl et al. [102] used positron emission tomography imaging, during which they had sexually or physically abused women with and without BPD listen to scripts describing neutral events or personalized scripts of the abuse. During the recall of the traumatic event, women with BPD lacked activation in the ACC, orbitofrontal PFC, and dorsolateral PFC. This was interpreted as a dysfunction of primarily inhibitory or emotion regulation areas in BPD during traumatic recall. Further, BPD patients and healthy controls were studied during the verbally cued recall of resolved or unresolved negative life events using fMRI [99]. In healthy controls, brain activation did not differ between the two types of events. For patients with BPD, fronto-temporal areas (insula, amygdala, ACC, left posterior cingulate Emotions and Memory in BPD

cortex, and right occipital cortex), the bilateral cerebellum, and the midbrain were activated more when unresolved events were imagined. Subjectively, BPD patients experienced significantly higher levels of anxiety, helplessness, and sadness and a lower level of feeling secure. The authors suggested that this response pattern might reflect an increased effortful, but insufficient, attempt to control intensive emotions during the recall of unresolved life events. In their follow-up study [101], the authors compared BPD patients’ and healthy controls’ neural responses to resolved and unresolved negative life events at two moments, separated by 1 year. Here, they found a decrease over time in the anterior cingulate, superior temporal lobes, insula, and right middle and superior frontal lobes even though no changes of emotional or sensory qualities during recall of unresolved events compared to resolved events were found. The authors suggest that alterations in neural correlates of unresolved life events may occur before symptom improvement, leading to the conclusion that these changes may be a preceding indicator of symptom improvement. A limitation of both studies that needs to be kept in mind is that half of the subjects in both studies had a diagnosis of PTSD. A study in which a small sample of 6 subjects with only BPD was compared to patients with both BPD and PTSD specifically addressed this issue [100]. fMRI was measured while participants recalled traumatic or negative but not traumatic life events. For subjects with BPD only, activation in response to traumatic experiences compared to nontraumatic experiences was greater in the orbitofrontal cortex, including Broca’s area. In subjects with BPD and PTSD, this comparison resulted in activation differences mainly in sensomotor and temporo-limbic brain areas, including the amygdala. This is in line with the fact that patients with BPD and PTSD reported higher levels of anxiety, helplessness, and sensory sensations during recall, suggesting that patients with BPD and PTSD experience traumatic events more emotionally, vividly, and sensorially [79, 106–108]. With respect to BPD, this study suggests that different neural networks are involved in the recollection of traumatic events depending on whether a subject with BPD has PTSD or not. Neurophysiological evidence suggests that, for BPD patients, memories of abandonment may be more arousing than for control participants [104]. In an fMRI study that compared memories of abandonment to neutral memories, Schmahl et al. [103] found that increases in blood flow in the bilateral dorsolateral PFC as well as to the right cuneus were greater in women with BPD than in Psychopathology 2014;47:71–85 DOI: 10.1159/000356360

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they remembered potential helpers as less helpful [97]. A recent study used the Adult Attachment Interview and found that BPD patients demonstrate more expressive language impairments, such as less complexity and more pauses during the interview [98]. Still, taken together, these findings suggest that BPD patients have a more negative tone in their memories. However, content analysis needs to be done to understand whether the remembered events are indeed more negative than those of control subjects or whether the negative events are simply remembered as more negative. As BPD patients actually are known to have high prevalence rates of abuse, it is reasonable to assume that patients actually have more burdensome events to remember.

Recent Autobiographical Memories In research that sought to find out whether BPD patients remember their recent experiences more negatively than matched controls, ambulatory assessment was used [109]. Retrospective ratings of specific emotions (happiness, interest, anxiousness, and anger) were monitored for 24 h in 50 patients with BPD and 50 healthy controls. BPD patients’ memories were biased negatively, remembering positive emotions as less intense and negative emotions as more intense than controls. Controls showed an overall positively biased recall pattern. Patients suffering from BPD perhaps react so strongly to past experiences because they remember those experiences as more negative than they perceived them at that time. Further experimental research is necessary to replicate these findings and to further analyze this valence-specific recall bias. Summary BPD patients do not generally produce overgeneral autobiographical memories in cued recall. Recent and earliest autobiographical memories appear to be more negatively toned. Also, aversive situations such as traumatic or unresolved negative life events are memorized with a stronger autonomous and neural response. These findings are highly relevant as they suggest that BPD patients suffer from intense negative memories, which may also bias the current relevance of emotional stimuli in BPD patients’ everyday lives.

Influence of Affective State on Memory Performance

It is well known that a learner’s affective state influences the way he or she processes and memorizes (emotional) information [38, 39]. This may be a particularly relevant 78


issue for BPD patients, who experience rapidly shifting, intense emotional states and who often suffer from a depressive mood. A straightforward number of studies were dedicated to the influence of mood or current affective state, as well as to the influence of concurrent MDD or state dissociation on learning and memory in BPD. Emotionality and Current Emotions When studying emotional memory processes, we need to consider the influence of the current affective state on learning and memory. With regard to the processing of emotional stimuli during affective states, an important concept is mood congruency. It has been shown that emotional information can be learned more easily if the valence of the content is congruent with the current affective state of the learner [38, 39]. As individuals with BPD mainly experience negative emotions such as sadness, anger, fear, and disgust [110], enhanced learning and retrieval of negative stimuli seems likely. An ambulatory assessment study tried to calculate the influence of current mood on a valence-specific recall bias in BPD [109]. However, due to methodological limitations, the study could only approximate the current affective state when rating past feelings and experiences. In this analysis, mood congruency could not sufficiently explain the valence-specific recall bias in BPD even though the research yielded significant contributions. Thus, more research is needed to draw conclusions about the effect of mood on learning and memory in BPD. A good starting point would be to include subjective ratings in experimental procedures that study emotions and memory in BPD. Comorbid MDD MDD is one of the most common co-occurrent axis I disorders in patients with BPD [2, 111]. This is important as individuals with MDD display deficits in autobiographical and semantic declarative memory, verbal fluency, and attentional performance [112–114], altered affective information processing [for a review, see 115, 116] with a bias favoring negative material [117–121], and an overgeneral memory bias in the AMT [83, 122, 123]. No influence of comorbid BPD on neuropsychological functioning was found in MDD patients [124]. Therefore, it has been suggested that comorbid MDD may be related to neuropsychological functioning rather than to BPD itself. To determine the influence of comorbid MDD in BPD patients, list learning of positive, negative, ambivalent, and neutral words was studied in 3 groups: patients with both MDD and BPD, patients with MDD only, and Winter/Elzinga/Schmahl


women without BPD. Abandonment memories were also associated with greater decreases in right anterior cingulate in women with BPD than in women without BPD. Here, subjective ratings of fear, anxiety, and distress did not differ between the groups, suggesting that differences in neuronal activity may not be due to a higher emotional burden of the abandonment scripts. In conclusion, studies on the effect of negative life events suggest that an altered activation pattern in temporo-prefrontal areas may be relevant for BPD patients’ emotional autobiographical memories and may mediate symptoms of BPD.

Dissociative Symptoms Patients with BPD often suffer from dissociative states [125], which are known to influence learning and memory [126–131]. One study showed remarkable neuropsychological deficits in BPD patients with pathological dissociation, including attention, working memory, executive functioning, long-term memory, and general cognitive abilities, while BPD patients without pathological dissociation only showed deficits in executive functioning [132]. Ebner-Priemer et al. [64] showed that dissociative symptoms impair BPD patients’ performance in affective conditioning. Furthermore, in a working memory paradigm with emotional interference [52], state dissociation in BPD patients was correlated with reduced amygdala and hippocampal activation during working memory performance. Similarly, during habituation, BPD patients reporting more dissociative symptoms had greater amygdala activation with repeated aversive picture viewing than BPD patients who reported fewer dissociative symptoms [66]. If dissociative symptoms impair learning in the laboratory, they may contribute to patients’ troubles with reallife situations. An established learning procedure outside Emotions and Memory in BPD

the laboratory is psychotherapy, which implies a relearning of habits and learning new strategies to think in a more helpful way. Dissociative symptoms correlated negatively with improvements in BPD patients’ general psychopathology after psychotherapy [133]. A similar influence of dissociative pathology on therapy outcome was found in patients with panic disorder [134], obsessivecompulsive disorder [135], depression [136], and anxiety disorder [136]. In sum, evidence suggests that dissociative symptoms impair emotional and nonemotional memory, probably associated with reduced amygdala activity. Therefore, when studying learning and memory in BPD patients, one should enquire and consider dissociative symptoms. Summary There is a glaring lack of studies elucidating the influence of BPD patients’ current affective states on memory processes. This void should be filled by future research. BPD patients’ depressive moods seem to go in hand with an attentional bias for negative information and a less specific recall of autobiographical memories. The evidence discussed suggests that dissociative symptoms may impair learning and memory. Thus, current emotions, dissociation, and depressive mood need to be taken into account when studying emotions and memory in BPD.

Discussion

This review has summarized studies on the effect of emotions and emotional content on learning and memory in BPD. Firstly, BPD patients tend to have an elevated susceptibility to attend to and encode emotional information. This becomes apparent when information processing and learning of more neutral information is disturbed by negative information. Secondly, in general, BPD patients remember explicit emotional information equally well as healthy control subjects, if it needs to be memorized for a short while, but BPD patients appear to have more difficulties forgetting or habituating to negative or personally relevant information. Therefore, in BPD patients, nondeclarative memory processes may be affected by negative information. Also, BPD patients’ autobiographical memories have a more negative tone than those of healthy controls and during recall of these memories BPD patients experience higher autonomous arousal and altered neural activity. Finally, the current affective state may influence learning and memory in BPD patients in ways similar to those in healthy control Psychopathology 2014;47:71–85 DOI: 10.1159/000356360

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healthy controls [68]. Patients with MDD and BPD performed worse than controls in immediate recall and recognition of these stimuli. They also recognized fewer words than did patients with MDD only. Patients with MDD and BPD as well as controls showed better recall of positive words than neutral words, while MDD patients revealed no valence bias. The authors interpreted their findings in terms of a mood congruency bias in MDD, which may differentiate prototypical MDD from depression in BPD patients. Further, Fertuck et al. [124] conducted a covariance analysis of mood and neuropsychological functioning in BPD and MDD and in MDD only. After controlling for anxiety, but not for overall emotional distress or anger, a superior performance was found for BPD and MDD patients regarding general intellectual functioning, as well as attention and psychomotor speed, but not memory performance. Calculating the influence of MDD severity on their results, no correlation was found in a directed forgetting paradigm [73] and in a study on earliest autobiographical memories [97]. Thus, overall, MDD in BPD may be associated with an attentional bias for negative information and a less specific recall of autobiographical memories. The evidence, however, supports the notion of general cognitive impairments in BPD patients with current MDD.

Limitations of Studies on Emotions and Memory in BPD

Sample Characteristics A challenge faced by studies on emotions and memory is that BPD patients may also exhibit impaired general cognitive functioning [132, 137, 138]. However, most studies on working memory and declarative memory cited in this article carefully controlled for possible group differences in cognitive functioning using a standardized test [45, 46, 48, 49, 52–56, 69] or at least considered education level [43, 50, 68, 70, 73]. Future research on emotions and memory should be equally careful and include relevant measures of cognitive functioning. Another limitation is that most of the studies summarized in this article included predominantly or exclusively female samples. This means that conclusions cannot be generalized to male BPD patients. No study included in this review recruited a male-only sample with BPD only. Further research is necessary in this area. Stimulus Selection and Presentation First of all, it is striking that the emotional content used in the studies mentioned is predominantly negative. Only few of these studies used any positive stimuli, generally showing no difference compared to the processing of neutral stimuli [46, 56, 68, 69, but not 47]. Also, it is still unknown whether the emotional content of stimuli or the mood changes that are induced by them actually lead to altered memory processes. This issue is particularly salient in studies using trauma-related stimuli, as those stimuli often trigger aversive tension or even dissociative symptoms [105, 139], which also alter memory processes. Thus, studies on learning and memory of emotional content need to use adequate designs that reduce mood induction or interference by, for example, using longer inter trial intervals or separate blocks of different valence categories. Also, adequate control conditions with words rated as neutral by the individual participant may improve research designs. 80


Comorbidities MDD was shown to influence BPD patients’ memory performance in a heterogeneous way: emotional interference and important autobiographical memories may be not affected by current depressive symptoms, whereas there is a tendency to recall cued memories less specifically when depressive symptoms are present. The ability to learn emotional material seems differentially affected, with MDD being associated with a bias towards negative information. Apart from MDD, it is important to consider that 30– 50% of individuals diagnosed with BPD suffer from comorbid PTSD [2, 140, 141]. Also, the neuronal networks found to be involved in pathological information processing in PTSD and BPD are similar [142–144]. PTSD in BPD patients was found to contribute to a possible negative bias in the emotional Stroop task [45]. Mauchnik et al. [65] found that a lack of differential affective conditioning is only present in BPD patients with comorbid PTSD, but not in patients with only BPD. This is in line with studies that found heightened conditionability in PTSD patients [145–147], with safety cues being conditioned more slowly in PTSD patients than in healthy controls [148, 149]. Up to now, studies on list learning in BPD have not explicitly taken into account whether or not participants had comorbid PTSD. Regarding autobiographical recall, no significant correlations between trauma, traumatic intrusions, and avoidance of intrusions with AMT results was found in BPD patients [94]. Driessen et al. [100] reported that traumatic events elicit stronger neural and physiological responses in BPD patients with PTSD than in BPD patients without PTSD. Further, PTSD patients, similarly to MDD patients, show an overgeneral autobiographical memory style [150–152]. Thus, while comorbid MDD in BPD patients seems to be associated with an encoding and recall bias for negative information, comorbid PTSD may play an important role in any of the memory processes discussed. However, the evidence is not exhaustive and future studies need to clarify the association of PTSD symptoms in BPD with alterations in emotional memory processes. Also, careful consideration of PTSD and MDD comorbidities is recommended when studying emotions and memory in BPD. Qualitative Literature Review The conclusions and speculations presented in this article were generated from a qualitative literature review on emotions and memory in BPD. The qualitative nature of this review needs to be considered as a limitation. If more comparable studies on emotions and memory in Winter/Elzinga/Schmahl


subjects or other patients. Comorbid depression in particular may impair and negatively bias information processing and memories, while dissociative symptoms seem to worsen memory performance independently of emotional valence. Apart from the difficulties controlling for current mood and affective state, studies focusing on emotions and memory face further methodological challenges.

BPD accumulate, a quantitative account in terms of a meta-analysis would be beneficial to gain deeper insights regarding this topic.

Clinical Implications

So far, the empirical evidence does not allow statement of firm clinical implications regarding memory functioning in BPD. When emotions and memory processes are altered in BPD, as has been stated above, they may well contribute to maintenance of the disorder: preferred processing of negative emotional stimuli may lead to the formation or activation of negative long-term memories, which furthermore seem to be particularly difficult to ‘forget’ for BPD patients. Moreover, negative information or memories may trigger intense mood states, which in turn may contribute to an attentional bias towards negative emotional information. Thus, BPD patients may easily be caught in a vicious cycle. Assuming that altered emotions and memory processes contribute to BPD psychopathology, specific therapeutic approaches may be helpful. BPD patients’ increased emotional distractibility may be reduced by training their ability to focus on target information. In this context, the work of Schweizer et al. [153] is interesting: healthy participants underwent training with an emotional n-back task and were tested before and after the training for the ability to concentrate on the working memory task as well as emotion regulation ability. Interesting: healthy participants improved compared to a control training in both domains. Even though the underlying mechanisms of this training are still a matter of debate [154], it would be highly relevant to try this emotional working memory training in patients with BPD. If patients with BPD suffer from burdensome autobiographical memories, trauma-focused therapy should be

considered when treating traumatized BPD patients. As habituation may be slower, prolonged exposure therapy may be considered as a complement to cognitive therapy. Also, because intense mood states and dissociation may be evoked, emotion regulation skills should be trained to reduce intense emotional states, as they may hamper learning and information processing. Still, these conclusions need more clinical support, for example from specific training studies. It would be best if studies applied respective memory tests before and after specific trainings or psychotherapy in order to see if memory processing alterations decrease after treatment. Then, it would be possible to judge if a treatment is able to alter specific memory processes. For example, with respect to the emotional Stroop task, Sieswerda et al. [47] showed that recovery in schema-focused therapy and transference-focused therapy was associated with reduced interference by emotional stimuli. In a sample in which 70% of the patients underwent cognitive behavioral or psychodynamic psychotherapy, Driessen et al. [101] found decreased neuronal activity in response to unresolved life events after 1 year. Also, predictors of psychotherapy success could be depicted. Fertuck et al. [155], for example, found that better baseline visual memory performance as well as better executive functioning predicted short durations of treatment in dialectical behavior therapy, supportive therapy, or drug treatment. These studies already point to the fact that the feasibility of the proposed studies is a difficult issue, as even in these studies treatments were intermixed. Therefore, the clinical implications derived from the evidence from this review need further support.

Disclosure Statement All authors have no conflict of interest to declare.

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Borderline personality disorder and mood.

Borderline personality disorder and self-conscious emotions in response to adult unwanted sexual experiences.

Borderline personality disorder and mood.

Impulsivity in borderline personality disorder.

Borderline personality disorder in adolescence.

Prescribing and borderline personality disorder.

Dissociation in schizophrenia and borderline personality disorder.

Psychotherapy for borderline personality disorder.

Epidemiology of borderline personality disorder.

Assessment and diagnosis of borderline personality disorder.

Increased serum prolactin in borderline personality disorder.

Pain in patients with borderline personality disorder.

Social judgement in borderline personality disorder.

Borderline Personality Disorder: Why 'fast and furious'?

Patient-reported outcomes in borderline personality disorder.

Borderline personality disorder in suicidal adolescents.

Mental capacity and borderline personality disorder.

Dissociation, borderline personality disorder, and childhood trauma.

Reducing Suicide Risk in Borderline Personality Disorder.

Social feedback processing in borderline personality disorder.

Impaired working memory and normal sustained attention in borderline personality disorder.

Psychopharmacologic treatment of borderline personality disorder.

The relationship between borderline personality disorder and bipolar disorder.

Co-occurrence of dissociative identity disorder and borderline personality disorder.