How Can We Reduce Aggressive Behavior in Individuals With Borderline Personality Disorder?

Borderline personality disorder (BPD) is a severe and chronic mental disorder. About 1-2 percent of people in the general population and up to 10 percent of psychiatric patients have BPD (Dubovsky & Kiefer, 2014). BPD, therefore, is one of the most frequent personality disorders, which leads to high levels of individual suffering, but also to high costs for health-care services due to the high frequency of medical and psychotherapeutic treatments. Individuals with BPD suffer from fast-changing emotions and personal goals as well as a negative image of themselves (American Psychiatric Association, 2013). They also tend to hold hostile feelings against others and to show highly impulsive and risky behaviors. One of the most widely known symptoms of BPD is self-injurious behavior, like cutting. This and other forms of self-directed aggression are frequently found in individuals with BPD and have been regarded as a “strategy” to regulate intense negative feelings, such as anger, guilt, or shame (Niedtfeld et al., 2010). However, individuals with BPD not only hurt themselves, they have also been found to react aggressively against other people: 73 percent of individuals with BPD report that they have acted out aggressively or violently during the last year, 58 percent were at least occasionally involved in physical fights, and 25 percent have used a weapon against another person at some point in their lives (for review, see Mancke et al., 2015)

Individuals with BPD most often act out aggressively when they feel threatened, rejected, or provoked by another person, particularly a significant other, such as intimate partner, family member, or close friend. These behaviors, which may be called “reactive aggression,” have been found in studies using self-report questionnaires, interviews as well as laboratory experiments. It is also noteworthy that (besides antisocial personality disorder) BPD is one of the most frequent disorders amongst prison inmates, especially amongst those incarcerated for domestic violence. Thus, reactive aggression can be regarded as an important and socially costly symptom of individuals with BPD. 

In recent years, we and others have tried to gain a better understanding of aggression in BPD. Based on these studies, we assume that individuals with BPD are highly sensitive to slight signals of threat or danger: They are prone to see the negative side in other people’s facial expressions and more easily ascribe aggression to others (Domes et al., 2009). As individuals with BPD often grew up in rather chaotic, abusive, or maltreating environments, such a perceptual tendency may have been adaptive in a sense that “smelling danger” may increase the likelihood to survive in an insecure world. Neurobiological studies have shown that this highly arousing experience for individuals with BPD is associated with increased activation in the amygdala, an ancient, subcortical brain region that is involved in threat processing, fear, and preparation of fight/flight responses (Schulze et al., 2016). Avoiding or withdrawing from social threats seems to be more difficult for individuals with BPD. In experiments, they were faster in approaching than avoiding angry faces or showed faster eye movements toward the eye regions of angry expressions, the most threatening part of these faces (Bertsch et al., 2013; 2017). Another aspect related to aggression is that individuals with BPD have problems in differentiating between their own feelings and feelings of others: other people’s anger is rubbing off on them and they have difficulties in regulating such feelings, which may increase the likelihood for aggressive reactions. 

Aggression has not been a specific subject of existing psychotherapeutic treatment programs for BPD although it may severely endanger the relationship between the patient and his/her psychotherapist or psychiatrist and other medical staff or patients. Therefore, we have designed a new group psychotherapeutic treatment, which specifically addresses feelings of anger and aggression. The program partly consists of elements of established therapy programs as well as new elements that are directly based on previous research findings. During this program, participants, for instance, learn to identify safety signals and how to regulate negative emotions. The efficacy of the program is currently being evaluated. So far, we only know that a “remission” or amelioration in some of the aspects related to aggression may take place since they are not found in individuals who were formerly suffering from BPD but (due to successful treatment) have not fulfilled the full diagnosis for this disorder in the past two years. For instance, the increased sensitivity to social threats decreases with symptom remission along with an improved perception of the own body and pain. We hope that the new treatment tools may help to further and faster reduce feelings of anger and aggression in individuals with BPD in the future. Details about the program as well as other studies of the Clinical Research Unit 256 “Mechanisms of Disturbed Emotion Processing in Borderline Personality Disorder” can be found here.

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.
Sabine C. Herpertz, M.D., is Chair of General Psychiatry at Heidelberg University/Medical Faculty Heidelberg and Medical Director of the Clinic for 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 ed. 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.

Domes, G., Schulze, L., & Herpertz, S.C. (2009). Emotion recognition in borderline personality disorder – a review of the literature. Journal of Personality Disorders, 23, 6-19.

Dubovsky, A.N. & Kiefer, M.M. (2014). Borderline personality disorder in the primary care setting. The Medical Clinics of North America, 98, 1049-1064.

Mancke, F., Herpertz, S.C., & Bertsch, K. (2015). Aggression in borderline personality disorder: a multidimensional model. Personality Disorders, 6, 278-291.

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, 383-391.

Schulze, L., Schmahl, C., Niedtfeld, I. (2016). Neural correlates of disturbed emotion processing in borderline personality disorder: a multimodal meta-analysis. Biological Psychiatry, 79, 97-106.