Effects of Oxytocin on Social Cognition and Empathy in Women with Borderline Personality Disorder

136 Pages·2014·2.63 MB·English

Albert-Ludwigs-U niversität Freiburg . Institut für Psychologie
Biologische und Differentielle Psychologie . D-79104 Freiburg

„Effects of Oxytocin on Social Cognition and Empathy in
Women with Borderline Personality Disorder“

Inaugural-Dissertation
zur
Erlangung der Doktorwürde
der Wirtschafts- und Verhaltenswissenschaftlichen Fakultät
der Albert-Ludwigs-Universität Freiburg. i. Br.

vorgelegt von:
Nicole Ower, geb. 01.05.1982 in Dernbach

WS 2013/14
Dekan: Prof. Dr. Dieter K. Tscheulin
Erster Gutachter: Prof. Dr. Markus Heinrichs
Zweiter Gutachter: Prof. Dr. Alexandra Philipsen
Promotionsbeschluss: 18.02.2014
Acknowledgements
Acknowledgements

I would like to dedicate these first two pages to all the people who supported me along the way as I
was finishing my dissertation.

Prof. Dr. Markus Heinrichs and Dr. Bernadette von Dawans are the first persons I’d like to express
my thanks to. Both of them have been supervising me from the very beginning of my work and
have been very inspiring and helpful with regards to both scientific questions and practical advice.
I’d like to thank Prof. Dr. Markus Heinrichs who always motivated me with his very supportive
and positive attitude and by the trust and belief he had in me and my work. He found a perfect
balance between support and clear guidance on the one hand, and granting me my own
responsibilities and confronting me with challenges on the other hand. Along with his brilliant
scientific knowledge and mentoring abilities, I also appreciated his sense of humor and the friendly
atmosphere he spread to his team. It was an honor for me to work with his successful but also very
sociable and friendly team.

Dr. Bernadette von Dawans I’d like to thank for her clear feedback on my work and the therapeutic
skills she sometimes applied when leading me through the jungle of questions I had in my mind
during our meetings. Her advice was essential for me in all the different phases of this work, and
her profound scientific skills helped me to improve my own.

Prof. Dr. Philipsen I’d like to thank for her great support in clinical and scientific questions.
Because of her excellent therapeutic skills she has always been a therapeutic role model for me.
But I’d also like to thank her for her professional support in theoretical and practical scientific
matters.

With a background in clinical psychology, it wasn’t very easy for me to find my way in a
biopsychology lab, where I felt a little lost at the beginning, and sometimes still today. Luckily all
of my colleagues turned out to be very nice people in a human sense, and very encouraging and
helpful scientists, too. P.D. Dr. Gregor Domes always had an open ear for me when I needed help
with methodological and statistical questions; I’m really impressed with his brilliant skills in
programming and statistics, and his helpful nature. Prof. Dr. Frances Chen was always interested in
my research, and discussions with her were very inspiring. Even though there were only few
opportunities to talk to her about my research, these discussions were, without a doubt, very
valuable to my work. I’d also like to thank Prof. Dr. Robert Kumsta and Dr. Valentina Colonnello
I
Acknowledgements
for their support and advice. Furthermore, I’d like to express my warm thanks to Dr. Tobias
Stächele who always listened to all of my worries and problems, big and small, and encouraged me
to keep going. He always made me believe in myself when I felt insecure and frustrated.

A special thanks goes to my doctoral colleagues, Dipl.-Psych Manuela Kanat, M.Sc. Psych. Marion
Schwaiger, M.Sc. Psych. Amalie Trüg, and Dipl.-Biol. Xenia Steinbach. We not only shared the
same room and many lunch breaks, we also shared worries, problems, questions and answers.
Working within this small group of doctoral colleagues was always very pleasant and enriching.

I’d like to thank all the great assistants and students who eagerly contributed to the long process of
the recruitment and data collection. Namely my thanks go to: M.Sc. Psych. Frederike Bjerregaard,
Dipl.-Psych. Vera Engel, Dipl.-Biol. Xenia Steinbach, Christina Rabenau, Judith Großmann,
Elisabeth Kraus, Teresa Travi and Ingrida Krivickaite. It was always a pleasure to have such an
ambitious and motivated team working with me.

My special thanks go to all the participants of this study: the healthy controls, and particularly the
patients suffering borderline-personality disorder for whom it certainly was a special challenge to
participate in our experiments. I hope that our conjoint effort will help to develop better treatment
opportunities for this severe disorder.

I’m deeply thankful to my family and friends. All of you supported me so much within the last few
years and I’m very grateful for your patience and understanding when I was stressed out. I’d like to
thank my mom who was probably more nervous and worried than I was at times, and who shared
all of my thoughts and feelings throughout this process. I’d like to thank my dad who always
doubtlessly believed in me and gave me advice when I needed it. I’d like to thank my brother and
his wife for listening to my worries, cheering me up, and distracting me with some leisure activity
whenever we met.

Finally I wish to thank all of my friends. I was in the noble position to have five excellent
psychologists around me throughout this entire time, who I can call my close friends. This was a
privilege in both a personal and a professional way. Anne von Lucadou and Simone Krais I’d like
to mention exclusively, as they constantly supported me and shared my ups and downs. Special
thanks go to the friends who read parts of my work and gave me feedback, but I’m also very
grateful for all the others who supported me emotionally and reminded me that there are more
things in life than work when I started to forget.

II
Abstract
Abstract

Borderline personality disorder (BPD) is a severe psychiatric disorder with long term impairment
in social functioning. Patients suffer from impulsivity and instability in moods, identity, and
interpersonal relationships. So far there is no appropriate medication, and psychotherapy only
shows effects for parts of the patient population. Empirical data shows first evidence that patients
who suffer from BPD display severe deficits in Theory of Mind (ToM), as well as in cognitive and
emotional empathy. So far there is no evidence for disturbed approach behavior in BPD, but
clinical observations report a pattern of overinvolvement and withdrawal in relationships, as
th
documented in the criteria of the 5 edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-V).

Oxytocin (OT) is known to show positive effects on emotion recognition, trust, stress response,
anxiety, bonding, and approach behavior. Considering the positive effects of OT on social
cognition and social behavior and the severe social impairments patients with BPD display, an
obvious next step is to investigate the possible compensative effects of OT on social deficits in this
disorder.

In our studies, we concentrated on the investigation of the effects of OT on ToM abilities, empathy,
and approach motivation in BPD. We tested 51 women with BPD, and 51 healthy women matched
for education and age in a randomized, double-blind, placebo controlled, between-subjects design.
Our subjects received 24 I.U. OT or placebo (PLC) 45 minutes before the experimental tasks. We
applied modified versions of the “Multifaceted Empathy Test” (MET) and the “Movie for the
Assessment of Social Cognition” (MASC), two ecologically valid measures to access cognitive and
emotional empathy and ToM abilities in our subjects. Our modified versions allowed us to
additionally measure approach behavior motivation in different social situations.

Our results show impairments in all the investigated features in women with BPD compared to
healthy controls. Patients showed reduced ToM abilities, impaired cognitive and affective empathy,
and less approach behavior motivation than HC. OT did not significantly effect ToM abilities and
cognitive empathy, but significantly enhanced affective empathy and approach behavior motivation
in both groups. These enhancing effects of OT varied with stimuli valence and situational factors.
Effects were stronger for stimuli of positive valence, for which BPD patients showed stronger
impairments. With respect to approach behavior motivation, OT enhanced approach behavior
motivation only in approach situations, and showed no effects in ambiguous or avoidance
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Abstract
situations; again, effects were stronger for stimuli of positive valence. Moreover, women with BPD
improved significantly more from OT than healthy women, indicating a stronger prosocial effect of
OT when social deficits are existent. A single dose of OT helped the heavily impaired BPD women
to reach comparable scores for affective empathy and approach behavior motivation to healthy
women under PLC.

Our data, for the first time, shows positive effects of OT on empathy and approach behavior
motivation in patients with BPD. These results are very promising for the possible therapeutic
value of OT in BPD and underline the need for further investigations in clinical trials, especially.

IV
Contents
Table of Contents
General Introduction ............................................................................................................................... 1
1. Oxytocin – social cognition and social behavior ................................................................................. 3
1.1 Oxytocin – social cognition and social behavior – state of research – ..............................................5
1.1.1 Effects of oxytocin on stress response and anxiety ....................................................................... 6
1.1.2 Effects of oxytocin on social cognition (emotion recognition, empathy) ...................................... 9
1.1.3 Effects of oxytocin on social interaction (attachment, trust and approach behavior) ................ 11
1.1.4 Data concerning clinical populations with impairments in social functioning ............................ 13
1.2 Summary of the effects of oxytocin on social behavior .................................................................. 15
2. Social cognition and social behavior ................................................................................................. 17
2.1 The need for social bonds and social approach behavior ............................................................... 17
2.2 Empathy. ......................................................................................................................................... 19
2.3 Theory of Mind and mentalizing ..................................................................................................... 22
3. Borderline personality disorder ........................................................................................................ 25
3.1 Clinical picture ................................................................................................................................. 25
3.1.1 Diagnostic criteria ........................................................................................................................ 25
3.1.2 Epidemiology ................................................................................................................................ 31
3.2 Neurobiological basis of borderline personality disorder ............................................................... 33
3.3 Etiology & therapy ........................................................................................................................... 36
4. Oxytocin, social cognition and borderline personality disorder – state of research – ..................... 40
4.1 Social cognition and empathy in borderline personality disorder .................................................. 40
4.1.1 Studies on empathy in real social interactions ............................................................................ 40
4.1.2 Studies on self-reported empathy ............................................................................................... 41
4.1.3 Studies on emotion recognition ................................................................................................... 41
4.1.4 Studies on mentalization using complex social stimuli ................................................................ 43
4.1.5 Preliminary conclusions ............................................................................................................... 44
4.2 Trust, affiliation and approach in borderline personality disorder ................................................. 45
4.2.1 Trust ............................................................................................................................................. 45
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4.2.2 Affiliation ...................................................................................................................................... 46
4.2.3 Approach ...................................................................................................................................... 46
4.3 State of research on oxytocin and borderline personality disorder ............................................... 47
4.4 Summary of the theoretical background and research question ................................................... 49
5. Overview of the design and data collection ...................................................................................... 51
5.1 Study design .................................................................................................................................... 51
5.2 Participants ...................................................................................................................................... 51
5.3 Test procedure ................................................................................................................................ 56
5.4 Substance administration ............................................................................................................... 57
5.5 Psychometric instruments .............................................................................................................. 58
6. Oxytocin and social cognition in women with borderline personality disorder ............................... 61
6.1 Introduction..................................................................................................................................... 61
6.2 Methods .......................................................................................................................................... 63
6.2.1 Participants................................................................................................................................... 63
6.2.2 Instrument “Movie for the Assessment of Social Cognition” ...................................................... 63
6.2.3 Psychological measures ................................................................................................................ 65
6.2.4 Statistical analysis......................................................................................................................... 65
6.3 Results…. ......................................................................................................................................... 66
6.3.1 Sample characteristics .................................................................................................................. 66
6.3.2 Behavioral data ............................................................................................................................ 67
6.3.3 Further analysis ............................................................................................................................ 70
6.4 Discussion ........................................................................................................................................ 72
7. Oxytocin and empathy in women with borderline personality disorder .......................................... 75
7.1 Introduction..................................................................................................................................... 75
6.2 Methods …………………………………………………………………………………………………………………………………….71
7.2.1 Participants................................................................................................................................... 76
7.2.2 Instrument “Multifaceted Empathy Test” .................................................................................... 76
7.2.3 Psychological measures ................................................................................................................ 78
7.2.4 Statistical analysis......................................................................................................................... 78
7.3 Results…. ......................................................................................................................................... 78
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Contents
7.3.1 Sample characteristics .................................................................................................................. 78
7.3.2 Behavioral data ............................................................................................................................ 79
7.3.3 Further analysis ............................................................................................................................ 82
7.4 Discussion ........................................................................................................................................ 84
8. Oxytocin and approach behavior motivation in women with BPD ................................................... 88
8.1 Introduction..................................................................................................................................... 88
8.2 Methods. ......................................................................................................................................... 89
8.2.1 Participants................................................................................................................................... 89
8.2.2 Instruments “Approach questions in MASC & MET” ................................................................... 89
8.2.3 Psychological measures ................................................................................................................ 90
8.2.4 Statistical analysis......................................................................................................................... 91
8.3 Results…. ......................................................................................................................................... 91
8.3.1 Sample characteristics .................................................................................................................. 91
8.3.2 Behavioral data ............................................................................................................................ 91
8.3.3 Further analysis ............................................................................................................................ 96
8.4 Discussion ........................................................................................................................................ 98
9. Final discussion & conclusions ........................................................................................................ 102
9.1 Summary and interpretation of the experimental data ............................................................... 102
9.2 Impact of the data in the context of research and implications ................................................... 103
9.3 Limitations ..................................................................................................................................... 104
9.4 Questions and goals for future research ....................................................................................... 105
10. Literature ....................................................................................................................................... 110

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Contents
Tables

Table 1: Sociodemographic variables of women with borderline personality disorder and healthy
comparison subjects ............................................................................................................................. 54
Table 2: Comorbid disorders of women with borderline personality disorder .................................... 55
Table 3: Comparison of psychometric values of women with borderline personality disorder and
healthy controls, in OT and PLC condition. ........................................................................................... 67
Table 4: MASC total and MASC subscores of HC and BPD patients in PLC and OT group .................... 68
Table 5: MASC error types of HC and BPD patients in PLC and OT group ............................................ 69
Table 6: Interpersonal Reactivity Index Scores of BPD patients and HC under PLC and OT ................. 79
Table 7: Cognitive and affective empathy scores in patients with BPD and HC under OT and PLC. .... 80
Table 8: Pearson's correlations of psychometric measures and MET scores ....................................... 83
Table 9: Differences in mood, anxiety, anger and tension at baseline and variations over the time-
course of the experiment ...................................................................................................................... 84
Table 10: Answer scores for the approach questions depending on the situation type ...................... 90
Table 11: MASC approach total and MASC approach subscores of HC and BPD patients in PLC and
OT group ................................................................................................................................................ 92
Table 12: MET approach scores in patients with BPD and HC under OT and PLC ................................ 94
Table 13: Correlations between MASC approach scale and MASC and MET original scales in our
sample (n = 98) ...................................................................................................................................... 97
Table 14: Correlations between MET approach- and MET original scales and IRI scales in our
sample (n = 98) ...................................................................................................................................... 98

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