Attentional Bias for Emotional Stimuli in Borderline Personality Disorder: A Meta-Analysis

Abstract

Background: In borderline personality disorder (BPD), attentional bias (AB) to emotional stimuli may be a core component in disorder pathogenesis and maintenance.

Sampling: 11 emotional Stroop task (EST) studies with 244 BPD patients, 255 nonpatients (NPs) and 95 clinical controls and 4 visual dot-probe task (VDPT) studies with 151 BPD patients or subjects with BPD features and 62 NPs were included.

Methods: We conducted two separate meta-analyses for AB in BPD. One meta-analysis focused on the EST for generally negative and BPD-specific/personally relevant negative words. The other meta-analysis concentrated on the VDPT for negative and positive facial stimuli.

Results: There is evidence for an AB towards generally negative emotional words compared to NPs (standardized mean difference, SMD = 0.311) and to other psychiatric disorders (SMD = 0.374) in the EST studies. Regarding BPD-specific/personally relevant negative words, BPD patients reveal an even stronger AB than NPs (SMD = 0.454). The VDPT studies indicate a tendency towards an AB to positive facial stimuli but not negative stimuli in BPD patients compared to NPs.

Conclusions: The findings rather reflect an AB in BPD to generally negative and BPD-specific/personally relevant negative words rather than an AB in BPD towards facial stimuli, and/or a biased allocation of covert attentional resources to negative emotional stimuli in BPD and not a bias in focus of visual attention. Further research regarding the role of childhood traumatization and comorbid anxiety disorders may improve the understanding of these underlying processes.

Fig. 1

Flowchart diagram for meta-analyses: summary of the literature search and study selection.

Fig. 2

a Forest plot of a meta-analysis of EST studies comparing patients with BPD with NPs. Positive effects denote stronger AB in BPD for generally negative emotional words. SMDs of interference scores were meta-analyzed. b Leave-one-out meta-analysis plot of the EST studies comparing patients with BPD with NPs and using generally negative emotional words as stimuli. The pooled SMDs prove to be quite stable when individual studies are omitted.

Fig. 3

a Forest plot of a meta-analysis of EST studies comparing patients with BPD with NPs. Positive effects denote stronger AB in BPD for BPD-specific and personally relevant negative emotional words. SMDs of interference scores were meta-analyzed. b Leave-one-out meta-analysis plot of the EST studies comparing patients with BPD with NPs and using BPD-specific and personally relevant negative emotional words as stimuli. The pooled SMDs prove to be quite stable when individual studies are omitted.

Fig. 4

a Forest plot of a meta-analysis of EST studies comparing patients with BPD with CCs. Positive effects denote stronger AB in BPD for generally negative emotional words. SMDs of interference scores were meta-analyzed. b Leave-one-out meta-analysis plot of the EST studies comparing patients with BPD with CCs and using generally negative words as stimuli. The effect remains in the range from -0.09 to 0.88, though leaving out the study of Sieswerda et al. [27] or of Waller and Button [29] leads to the 95% CI covering zero.

Fig. 5

a Forest plot of a meta-analysis of EST studies comparing CCs with NPs. Positive effects denote a trend towards a stronger AB for generally negative emotional words in CCs. SMDs of interference scores were meta-analyzed. b Leave-one-out meta-analysis plot of the EST studies comparing CCs with NPs and using generally negative words as stimuli. The leave-one-out analysis indicated a wide variance in the pooled SMD from 0.183 (leaving out the study of Völker et al. [26]) to 0.544 (leaving out the study of Sieswerda et al. [27]).

Fig. 6

Forest plot of a meta-analysis of the dot-probe studies with negative versus neutral faces and with medium presentation time (200-500 ms) comparing patients with BPD with NPs. SMDs denote AB toward, negative SMDs AB away from negative faces (avoidance).

Fig. 7

Forest plot of a meta-analysis of the dot-probe studies with positive versus neutral faces and with medium presentation time (200-500 ms) comparing patients with BPD with NPs. Positive SMDs denote AB toward positive faces, negative SMDs AB away from positive faces.

Fig. 8

Leave-one-out meta-analysis plot of the dot-probe studies with positive versus neutral faces and with medium presentation time (200-500 ms) comparing patients with BPD with NPs. Positive SMDs denote AB toward positive faces, negative SMDs AB away from positive faces.