Adolescents With Borderline Personality Disorder Struggle With Controlling Anger and Aggression

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Thinking of patients with borderline personality disorder (BPD), many people may imagine persons with self-harming behavior, such as cutting or burning. Indeed, a high percentage of this patient group — which is characterized by high impulsivity, identity disturbance, instability in interpersonal relationships, deficits in emotion regulation, and intense feelings of anger (American Psychiatric Association, 2013) — engages in self-directed aggressive behavior (70 percent; Zanarini et al., 2008). Evidence suggests that self-directed aggressive behavior in patients with BPD may be an effort to regulate intense aversive emotions, such as anger (Niedtfeld et al., 2010). Furthermore, a high amount of BPD patients show aggressive behavior directed against other persons (73 percent; Newhill et al, 2009) — termed other-directed aggression — which comes along with great suffering among the patients and their social environment, too. Aggressive behavior thus impairs BPD patients’ interpersonal relationships in a special way.

Our workgroup and others have made great efforts in recent years to better understand the causes of self- and other-directed aggressive behavior in this group of patients. Based on the findings of previous studies, we assume that one important aspect contributing to BPD patients’ aggressive behavior is their high sensitivity to interpersonal threat signals (Bertsch et al., 2013; 2017). Typical examples of interpersonal threat are situations in which patients with BPD feel rejected by others. These situations usually elicit intense feelings of anger. We believe that patients with BPD tend to act out aggressively due to their difficulty regulating intense feelings of anger (Mancke et al., 2015).

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Interestingly, previous research has primarily focused on adults with BPD and we do not know much about aggression in younger patients. However, previous studies suggest that adolescents’ experiences of social exclusion are associated with higher emotional intensity in patients with BPD (Lawrence et al., 2011). In addition, like adults, adolescents with BPD have great difficulties in regulating emotions (Ibraheim et al., 2017).

We conducted a study that examined rejection-related feelings of anger and subsequent aggressive reactions in female adolescents with BPD. In this study, participants listened to scripts describing a social rejection situation and the elicited feelings of anger, followed by descriptions of self-directed aggression or other-directed aggression against the rejecting person. The situations presented in the scripts had been carefully selected together with patients suffering from BPD to ensure that they represented typical anger eliciting rejection situations. Participants were listening to the scripts via headphones and were instructed to imagine the described scenes as vividly as possible. During the whole experiment, they were lying in a magnetic resonance imaging scanner, so that we were able to investigate the neural correlates of rejection-related feelings of anger and aggressive behavior impulses in the participants while they were listening to the scripts.

Our results revealed an increased activation in the insula and putamen, brain regions associated with emotional responding and saliency (Mühlberger et al., 2010; Schulze et al., 2016; Zink et al., 2003). Increased activation was also observed in the inferior frontal gyrus, a region that has been associated with different forms of self-control and self-regulation, including the regulation of emotions and particularly of feelings of anger (Fabiansson et al., 2011; Tabibnia et al., 2011). The results of our study thus suggest that, as early as adolescence, patients with BPD show enhanced emotional reactivity to situations of perceived rejection by others and at the same time strong efforts to control rejection-related feelings of anger and subsequent aggressive impulses.

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What implications might our recent results have for clinical practice? We think that it could be important to increasingly implicate strategies targeting self-control and emotion regulation in the therapeutic process with adolescents with BPD symptomatology. Learning adaptive strategies to regulate and control one’s emotional states might be helpful to reduce aggressive behavior at an early age and could thus help adolescents with BPD to build positive relationships with others from an early age on.

Summing it up:

  • Self- and other-directed aggressive behavior is frequently observed in patients with BPD and often results from intense feelings of anger

  • We found evidence on a neural level that adolescent patients with BPD show stronger emotional reactions to anger-inducing interpersonal rejection situations and high efforts to control subsequent feelings of anger and aggressive behavior impulses

  • These results suggest the need for early intervention strategies in BPD to help adolescents at developing positive relationships.

If you want to read more about this topic, please check out our recent publication:
Krauch, M., Ueltzhöffer, K., Brunner, R., Kaess, M., Hensel, S., Herpertz, S. C., & Bertsch, K. (2018). Heightened salience of anger and aggression in female adolescents with borderline personality disorder – A script-based fMRI study. Frontiers in Behavioral Neuroscience, 12, 57.

Marlene Krauch is a Ph.D. student at the work group Personality Disorders in the Department of General Psychiatry at the Center for Psychosocial Medicine at Heidelberg University in Germany. Katja Bertsch, Ph.D., is head of the work group Personality Disorders in the Department of General Psychiatry at the Center for Psychosocial Medicine at Heidelberg University in Germany.

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edn. Arlington, VA: American Psychiatric Publishing.

Bertsch, K., Gamer, M., Schmidt, B., Schmidinger, I., Walther, S., Kästel, T., Schnell, K., Büchel, C., Domes, G., & Herpertz, S.C. (2013). Oxytocin and reduction of social threat hypersensitivity in women with borderline personality disorder. American Journal of Psychiatry, 170, 1169-1177.

Bertsch, K., Krauch, M., Stopfer, K., Haeussler, K., Herpertz, S.C., & Gamer, M. (2017). Interpersonal threat sensitivity in borderline personality disorder: an eye-tracking study. Journal of Personality Disorders, doi: 10.1521/pedi_2017_31_273.

Fabiansson, E.C., Denson, T.F., Moulds, M.L., Grisham, J.R., and Schira, M.M. (2012). Don’t look back in anger: neural correlates of reappraisal, analytical rumination, and angry rumination during recall of an anger-inducing autobiographical memory. Neuroimage, 59, 2974-2981. doi: 10.1016/j.neuroimage.2011.09.078

Ibraheim, M., Kalpakci, A., and Sharp, C. (2017). The specificity of emotion dysregulation in adolescents with borderline personality disorder: comparison with psychiatric and healthy controls. Borderline Personality Disorder and Emotion Dysregulation, 4, 1. doi: 10.1186/s40479-017-0052-x

Lawrence, K.A., Chanen, A.M., and Allen, J.S. (2011). The effect of ostracism upon mood in youth with borderline personality disorder. Journal of Personality Disorders, 25, 702-714. doi: 10.1521/pedi.2011.25.5.702

Mancke, F., Herpertz, S.C., & Bertsch, K. (2015). Aggression in borderline personality disorder: A multidimensional model. Personality Disorders: Theory, Research, and Treatment, 6(3), 278.

Mühlberger, A., Wieser, M.J., Gerdes, A.B., Frey, M.C., Weyers, P., and Pauli, P. (2010). Stop looking angry and smile, please: start and stop of the very same facial expression differentially activate threat-and reward-related brain networks. Social Cognitive and Affective Neuroscience, 6, 321-329. doi: 10.1093/scan/nsq039

Niedtfeld, I., Schulze, L., Kirsch, P., Herpertz, S.C., Bohus, M., & Schmahl, C. (2010). Affect regulation and pain in borderline personality disorder: a possible link to the understanding of self-injury. Biological Psychiatry, 68(4), 383-391.

Newhill, C.E., Eack, S.M., & Mulvey, E.P. (2009). Violent behavior in borderline personality. Journal of Personality Disorders, 23(6), 541-554.

Schulze, L., Schmahl, C., and Niedtfeld, I. (2016). Neural correlates of disturbed emotion processing in borderline personality disorder: a multimodal metaanalysis. Biological Psychiatry, 79, 97-106. doi: 10.1016/j.biopsych.2015.03.027

Tabibnia, G.,Monterosso, J.R., Baicy, K., Aron, A.R., Poldrack, R.A., Chakrapani, S., et al. (2011). Different forms of self-control share a neurocognitive substrate. Journal of Neuroscience, 31, 4805-4810. doi: 10.1523/JNEUROSCI.2859-10.2011

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