Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation
(2017) 4:6
DOI 10.1186/s40479-017-0057-5
RESEARCH ARTICLE
Open Access
Anger and aggression in borderline
personality disorder and attention deficit
hyperactivity disorder – does stress matter?
Sylvia Cackowski1*, Annegret Krause-Utz2, Julia Van Eijk3, Katrin Klohr1, Stephanie Daffner1, Esther Sobanski4
and Gabriele Ende3
Abstract
Background: The impact of stress on anger and aggression in Borderline Personality Disorder (BPD) and Attention
Deficit Hyperactivity Disorder (ADHD) has not been thoroughly investigated. The goal of this study was to
investigate different aspects of anger and aggression in patients with these disorders.
Methods: Twenty-nine unmedicated female BPD patients, 28 ADHD patients and 30 healthy controls (HC)
completed self-reports measuring trait anger, aggression and emotion regulation capacities. A modified version of
the Point Subtraction Aggression Paradigm and a state anger measurement were applied under resting and stress
conditions. Stress was induced by the Mannheim Multicomponent Stress Test (MMST).
Results: Both patient groups scored significantly higher on all self-report measures compared to HCs. Compared to
ADHD patients, BPD patients reported higher trait aggression and hostility, a stronger tendency to express anger
when provoked and to direct anger inwardly. Furthermore, BPD patients exhibited higher state anger than HCs and
ADHD patients under both conditions and showed a stress-dependent anger increase. At the behavioral level, no
significant effects were found. In BPD patients, aggression and anger were positively correlated with emotion
regulation deficits.
Conclusions: Our findings suggest a significant impact of stress on self-perceived state anger in BPD patients but
not on aggressive behavior towards others in females with BPD or ADHD. However, it appears to be pronounced
inwardly directed anger which is of clinical importance in BPD patients.
Keywords: Borderline personality disorder, Attention deficit hyperactivity disorder, Anger, Aggression, Impulsivity,
Emotion regulation, Stress
Background
Affect dysregulation and related problems with impulsivity, anger control deficits and aggression constitute a
characterizing symptom cluster in Borderline Personality
Disorder (BPD) [1–3] and Attention Deficit Hyperactivity
Disorder (ADHD) [4–7]. Aggression in BPD patients
manifests itself in self-destructive behavior (e.g., high risk
behavior, self-injury) or externally directed (impulsive) aggression [8, 9]. The latter can also be observed in ADHD
* Correspondence: sylvia.cackowski@zi-mannheim.de
1
Department of Psychosomatic Medicine and Psychotherapy, Central
Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg
University, J5, D-68159 Mannheim, Germany
Full list of author information is available at the end of the article
patients and is reflected in low frustration tolerance and
recurrent temper tantrums [5]. Impulsive aggression is
characterized by behavioral disinhibition, alongside a lack
of planning and concerns about consequences [10].
The occurrence of aggressive behavior may be influenced by different personal or situational variables (for
overview see [11]), such as gender [12, 13], educational
level, income [14], certain personality traits (e.g. impulsivity) [15, 16] or provocation [17, 18]. Gender differences have been frequently discussed in aggression
research and the type of aggression appears to play a
crucial role [12, 13]. Evidence has shown that men are
physically more aggressive, but not more aggressive in
general, and that provocation evokes aggression to the
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:6
same extent in men and women [13]. Some studies also
support these findings in BPD patients [18–20].
There is further indication that unspecific affective
arousal or stress can enhance the likelihood of aggressive
behavior [11, 21]. This should be taken into account when
investigating aggression in BPD, as these patients frequently experience high levels of aversive arousal [22, 23].
While there is evidence for stress effects on the related
construct of impulsivity in BPD patients [24–27], previous
studies examining aggression in BPD have not systematically investigated the influence of stress. Furthermore, the
high comorbidity rates of BPD with substance disorder, bipolar disorder, antisocial personality disorder and ADHD
[28–30] are important to consider, as these disorders are
already associated with elevated levels of impulsivity and
aggression [27, 31–34].
Previous studies, which used well-established selfrating scales (i.e. the State-Trait Anger Expression Inventory, STAXI; [35], Buss-Perry Aggression Questionnaire, BPAQ; [36]), revealed elevated levels of anger and
aggression in BPD patients [18–20, 24, 37, 38]. McCloskey et al. [19] found significantly higher scores in trait
anger and aggression in female and male BPD patients
compared to healthy controls (HCs) and patients with
non-cluster-B personality disorders. Beyond self-report
measures, the Point Subtraction Aggression Paradigm
(PSAP; [39]) has been frequently used for the behavioral
assessment of aggression (in terms of point-subtracting
responses to a fictitious- opponent), and has already
been applied to BPD patients [18–20, 37]. For example,
New et al. [18] demonstrated that a gender-mixed sample
of BPD patients with intermittent explosive disorder
reacted more frequently with aggressive responses in the
PSAP compared to HCs. However, in this study, it was unclear whether comorbid intermittent explosive disorder at
least partly explained elevated aggression scores in BPD.
Although previous studies excluded comorbid conditions such as bipolar disorder or current substance
abuse [18, 19], to our knowledge, no previous studies
have controlled for comorbid ADHD. Adult ADHD is a
highly prevalent comorbid condition in BPD patients
(about 38%; [28, 30, 40]) and is also characterized by
impulsivity and anger control problems [4, 5]. Previous
research in adult ADHD samples has revealed higher
self-reported trait anger and poorer anger control
(STAXI; [35]) in ADHD patients compared to HCs [32,
41] and also compared to a control group with low
ADHD symptoms [42]. In the latter study, individuals in
the ADHD group reported significantly higher anger,
lower anger control and more dysfunctional anger expression (e.g., noisy arguing, physical aggression directed
towards objects). Studies with self-report measures of
anger and aggression comparing ADHD and BPD patients are scarce and provide partly inconsistent finding
Page 2 of 13
[32, 41]. Although there are many studies indicating an
impaired behavioral inhibition in ADHD patients compared to HCs [27, 32, 43, 44], little is known regarding aggression in adult ADHD patients. Most studies assessing
aggressive behavior have been conducted with children
and adolescents [45–47], but studies examining aggression
in adult ADHD patients (especially females) compared to
healthy and clinical control groups are lacking.
The aim of this study was to further investigate the nature of anger and aggression in BPD and ADHD patients
by examining the impact of stress on these features, while
controlling for comorbid ADHD in BPD patients and vice
versa. In the main study, we hypothesized that female
BPD and ADHD patients would show higher scores in
self-report measures of anger and aggression compared to
healthy women. We were also interested in a potential
group difference and stress condition effect in selfreported state anger and behavioral aggression. We
expected more state anger and aggressive responses in patients after stress induction compared to HCs. Another
aim of our study was to investigate correlations between
self-reported emotion regulation capacities and measures
of aggression in female BPD and ADHD patients.
Methods
Sample
A total number of 93 females between 18 and 43 years of
age participated in the study. Recruitment took place at the
Department of Psychosomatic Medicine and Psychotherapy
and the Department of Psychiatry and Psychotherapy at the
CIMH. Participants were additionally recruited via advertisements in newspapers, on websites and on disorderspecific internet forums, as well as through flyers for therapists. The BPD and ADHD sample consisted of outpatients
and patients who currently did not make use of psychotherapeutic treatment. None of the participants was in
inpatient treatment as the investigation took place.
Five participants had to be excluded from final data analysis in the main study: two HCs were excluded due to
drug abuse and a diagnosis of current dysthymia, one BPD
patient cancelled participation before study completion
and data of two other BPD patients could not be obtained
due to technical difficulties. The final sample consisted of
29 female patients with BPD, 28 with ADHD and 30 HCs.
Clinical diagnostics and basic assessments
All participants underwent diagnostic assessments including the Structured Clinical Interview for DSM-IV
Axis-I (SCID-I; [48]) and the Borderline Section of the
International Personality Disorder Examination (IPDE;
[49]; inter-rater-reliability κ =0.77). In addition, the
Standard Progressive Matrices Test (SPM; [50]) was
completed by all participants in order to estimate
intelligence.
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:6
Further clinical variables were assessed with questionnaires for borderline symptom severity (Borderline
Symptom List-23, BSL-23; [51]) and dysphoric mood
(Beck Depression Inventory II, BDI-II; [52]). The Barratt
Impulsiveness Scale-11 (BIS-11; [53]) was applied as a
measure for impulsivity. Emotion regulation capacities
were assessed by the Difficulties in Emotion Regulation
Scale (DERS; [54]). A higher DERS total score implies
better emotion regulation capacities. Subjective stress
levels during the experiment were rated on a ten-point
Likert scale (0 = “not at all” to 9 = “extremely”).
Inclusion and exclusion criteria
For inclusion into the BPD group patients had to fulfil at
least five DSM-IV criteria for BPD [53] as assessed by
the IPDE. For verification of ADHD diagnosis, as well as
exclusion of ADHD diagnosis in BPD patients, four different measurements (validated German versions) were
applied: 1) The short version of the Wender Utah Rating
Scale (WURS-k; [55]) was used to assess childhood
ADHD symptoms. This self-report scale consists of 25
items which are answered on a five-point Likert scale (0
= “not applicable” to 4 = “applicable”). For the assessment of ADHD symptoms in adulthood 2) the ADHDSelf-Rating scale (ADHD-RS; [56]) and 3) the Connor
Adult ADHD Rating Scale - Self-Report: Long Version
(CAARS-S:L; [57]) were used. Both scales are based on
the DSM-IV criteria for ADHD [58]. Furthermore, 4) the
Wender-Reimherr Adult Attention Deficit Disorder
Scale (WRAADDS; [59]) was applied, which is a clinical
interview conceptualized for adult ADHD to assess the
core features of inattention, hyperactivity and impulsivity, and additional features comprising temperament,
affective lability, stress tolerance and disorganization.
Experienced clinical psychologists and psychiatrists clarified possible inconsistencies in the self-measurements by
the WRAADDS [59] and integrated external assessments
(e.g. school reports, interviews with parents or relatives)
to reach the diagnosis of ADHD. Only in case of clear
verification of the ADHD symptomatology patients were
included in the study. In ADHD patients, a possible
BPD diagnosis was excluded via the IPDE.
Exclusion criteria for all participants comprised the
use of psychotropic medication within two weeks prior
to study, significant somatic disorders, pregnancy or
mental deficiency. A few patients (11%) gradually
reduced intake of their psychotropic medication and
stopped intake two weeks before the study took place.
Approval for this procedure was given only, if certain
conditions were met: medication was reduced in consultation with the attending physician of the patient, the
general state and living conditions were mostly stable
and the patient had the intention to try a medication
free period anyway. Lifetime history of any psychiatric
Page 3 of 13
disorder was an exclusion criterion for HCs. BPD and
ADHD patients were excluded if they had a lifetime history of bipolar affective disorder or psychotic disorder, a
current suicidal crisis and/or substance abuse within the
last two months (a lifetime diagnosis of substance
dependence was allowed). All clinical assessments and
interviews were conducted by well-trained clinical
psychologists and psychiatrists.
Self-report measures of anger and aggression
Subjects completed three questionnaires assessing anger
and aggression: the Brown-Goodwin Lifetime History of
Aggression (BGLHA; [60]), the Buss-Perry Aggression
Questionnaire (BPAQ; [36]) and the State-Trait Anger
Expression Inventory (STAXI; [35]). The BGLHA assesses instances of fighting, assaults, temper tantrums,
school discipline problems, problems with superiors,
antisocial behavior not involving police, as well as antisocial behavior involving police. Each item is rated on a
scale from 0 to 4, indicating the frequency of antisocial
events ranging from “never” to “more than four times”.
The BPAQ is a measure of trait aggressiveness with 29
items related to four subscales: anger, hostility, physical
and verbal aggressiveness. Participants rate the extent to
which each item characterizes themselves from 1 (extremely uncharacteristic) to 4 (extremely characteristic).
The trait part of the STAXI assesses one’s disposition to
experience anger and consists of the two subscales “temperament” (propensity to experience anger without specific provocation) and “reaction” (anger experience when
provoked). Anger expression is gathered via three subscales: “anger in” (tendency to suppress angry feelings),
“anger out” (tendency to express anger toward other
people or objects) and “anger control” (ability to control
expressions of anger). The state of the STAXI was developed for repeated measurement and measures the intensity of current subjective anger. All items are rated on a
4-point Likert scale ranging from 1 (not at all/almost
never) to 4 (very much/almost always).
Behavioral assessment of aggression
The Point Subtraction Aggression Paradigm (PSAP;
[39]) is a widely used computer-based measure of aggressive responses to provocation. The participant is
instructed to accumulate points, which can be exchanged for money. Provocation through point subtractions during the game is ascribed to another player but
is in fact pre-determined by the program. Three different
action options (buttons) are given: 1) by pressing button
A approximately 100 times, ten points are earned; 2) by
pressing button B ten times, ten points from the (fictitious) opponent are subtracted; and 3) by pressing button C ten times, the participant can protect his points
from point subtractions by the opponent. After the B or
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:6
C button is pressed, a provocation free interval (PFI) is
started, during which no point subtraction occurs. The
number of button B responses is used as an indicator of
aggression, as B button presses deliver an aversive stimulus through point-subtraction to the opponent.
There exist several versions of the PSAP, which differ
for example in the number of buttons (two buttons vs.
three buttons) (i.e. [61, 62]), number and duration of sessions (10 minutes or 25 minutes, repeated twice or more)
(i.e. [63–65]) or the PFIs (45 seconds – 500 seconds) (i.e.
[37, 64, 65]).
In the present study, a 12.5-minute version of the
PSAP with a high provocation-rate was used (provocations occurred every 6–60 seconds and PFI was set at
31.25 seconds) in order to adapt the PSAP to our test
battery (which also comprised other laboratory tasks; see
[27]). In our study, a video recording of the opponent
was shown during the whole session in the top right corner of the computer screen, and the participant was told
that the opponent would also see the participant via a
webcam. Because of the modifications, a pilot study with
male BPD and ADHD patients and HCs was conducted
to test whether our version of the PSAP was sensitive
for stress-dependent changes in behavioral aggression
(see Additional file 1).
Stress induction
For stress induction, the Mannheim Multicomponent
Stress Test (MMST; [66, 67]) was used, which consists of a
combination of an emotional (aversive pictures), a sensory
(white noise displayed over headset), a cognitive (calculation under time pressure: Paced Auditory Serial Addition
Task (PASAT-C); [68]), and a motivational (loss of money
due to calculation errors) stressor. To ensure that the stress
induction was successful, subjective stress was assessed
with a 10-point Likert scale, as well as via heart rate.
Procedure
This study was approved by the Ethics committee of the
Medical Faculty Mannheim/Heidelberg University and
was conducted in accordance with the Declaration of
Helsinki. After participants were informed about the background and procedure of the experiment, written informed consent was obtained and participants underwent
diagnostics and completed the basic clinical assessments.
Participants completed the PSAP on two different days
(within a 3-day interval). The order of the resting and
stress conditions was randomized. During both sessions,
participants completed the STAXI state part and the
Likert scale for subjective stress. The STAXI was completed before and after PSAP performance (analyses
were performed with the means of the two scores). Additionally, at the stress session a baseline heart rate assessment was conducted for five minutes. Afterwards, the
Page 4 of 13
stress induction with the MMST was conducted for five
minutes, while heart rate was measured simultaneously.
Heart rate was assessed in five seconds intervals by a
chest belt and wirelessly transmitted to the heart rate receiver attached to the participant’s wrist. Subsequently
the subjective stress rating and the STAXI state were
completed and the PSAP was started. At the end of the
study, participants were debriefed, thanked and paid for
their participation.
Data analysis
The congruence of data with normal distribution assumptions was tested using Kolmogorov-Smirnov tests.
Some scores in the main study were found to be not
congruent with normal distribution. Therefore, differences between groups were initially tested using nonparametric tests (Mann–Whitney U, Kruskal-Wallis H
and Wilcoxon test). Because there were no differences in
the patterns of results when using nonparametric tests
versus parametric tests (analyses of variance (ANOVA)
or multivariate ANOVA (MANOVA) and students’ ttests), the results of parametric analyses are presented
for the purpose of simplicity. State variables (anger, aggression, stress ratings, heart rate) were analyzed using
3× 2 repeated measure ANOVAs (rm-ANOVA) with
group (HC vs. BPD vs. ADHD) as between-factor and
condition (resting vs. stress) as within-factor. In case of
significant effects, post-hoc Tukey-HSD tests were used
for group comparisons and paired t-tests for within-group
comparisons. Bivariate Pearson’s product–moment correlations between self-reported emotion regulation capacities (DERS) and the total scores of the anger and
aggression measures were computed in BPD and ADHD
patients. Bonferroni correction was used to account for
multiple comparisons. Threshold for statistical significance was set at p < 0.05, two-tailed. Effect sizes partial eta
squared (η2p), Cohen’s d [69] and Cramér’s V (φc) are
reported in case of significant effects.
Results
Demographic and clinical variables
The means and SD for demographic and clinical variables, as well as patients’ comorbid psychiatric disorders
are presented in Table 1.
There were no significant differences in demographic
variables, except for the education level, with ADHD patients showing fewer years of education than HCs. All
three groups differed significantly in the BDI, the BIS-11
and the DERS. While BPD patients showed the highest
BDI scores and the lowest DERS score, the most elevated BIS-11 scores were found in ADHD patients. As
expected, BPD patients reported significantly higher
BSL23 scores than HCs and ADHD patients. For further
characterization of the samples, also the ADHD scales
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:6
Page 5 of 13
Table 1 Demographic and clinical variables in healthy control participants (HC), patients with Borderline Personality Disorder (BPD)
and patients with Attention Deficit Hyperactivity Disorder (ADHD)
HC (n= 30)
M ± S.D.
BPD (n= 29)
M ± S.D.
ADHD (n= 28)
M ± S.D.
F/χ2
p
27.53 ± 6.60
27.07 ± 6.51
30.11 ± 7.96
1.70
.189
111.70 ± 10.50
107.07 ± 12.32
105.46 ± 12.71
2.18
.119
100-300€
7 (23)
8 (28)
6 (21)
350-500€
6 (20)
3 (10)
4 (14)
3.00
.934
550-700€
7 (23)
6 (21)
4 (14)
750-1000€
3 (10)
3 (10)
3 (11)
+ 1000€
7 (23)
9 (31)
11 (39)
Less than 9 years
0 (0)
0 (0)
4 (14)
9 years
0 (0)
1 (3)
3 (11)
15.60
.016b
.30
10 years
8 (27)
9 (31)
10 (36)
13 years
22 (73)
19 (66)
11 (39)
MDD
4 (14)
1 (4)
Anxiety disorder
11 (38)
5 (18)
Substance abuse
0 (0)
0 (0)
Eating disorder
8 (28)
3 (11)
PTSD
13 (45)
1 (4)
OCD
3 (10)
0 (0)
Age
η2p/φc
Intelligence (IQ)
Raven SPM
Income, n (%)
Years of education, n (%)
Current co-morbidities, n (%)
Medication, n (%)d
No stable medication
30 (100)
23 (88)
25 (89)
Intake stopped 2 week prior to the study
0 (0)
3 (12)
3 (11)
WURS-k
6.67 ± 5.71
29.62 ± 16.40
40.29 ± 13.83
53.11
≤.001a,b,c
.56
ADHD-RS
6.53 ± 5.45
19.93 ± 8.68
34.25 ± 7.65
102.64
≤.001a,b,c
.71
a,b,c
CAARS
31.10 ± 17.59
89.66 ± 26.10
121.18 ± 23.58
118.91
≤.001
.74
BSL23
2.60 ± 4.12
47.90 ± 20.54
17.18 ± 11.89
81.74
≤.001a,b,c
.66
a,b,c
BDI-II
2.17 ± 3.26
32.00 ± 11.55
16.46 ± 11.35
73.30
≤.001
.64
BIS-11
53.40 ± 7.43
66.45 ± 10.49
81.29 ± 10.42
62.16
≤.001a,b,c
.60
91.31
a,b,c
.69
DERS
145.00 ± 12.92
85.14 ± 19.31
103.18 ± 19.59
≤.001
Note: Data are presented in means ± standard deviations, statistical group comparisons by analysis of variance (degrees of freedom (df): F(2, 84)) and χ2 -test for
income (df = 8) and education (df = 6); p-value; effect size in η2p and φc;
MDD Major Depressive Disorder, PTSD Posttraumatic stress disorder, OCD Obsessive Compulsive Disorder, WURS-k Wender Utah Rating scale short version,
ADHD-RS Attention Deficit Hyperactivity self-rating scale, CAARS Connor Adult ADHD Rating Scale, BSL-23 Borderline Symptom List-23, BDI-II Beck Depression
Inventory II, BIS-11 Barratt Impulsiveness Scale, DERS Difficulties in Emotion Regulation Scale
a
HC vs. BPD significant differences
b
HC vs. ADHD significant differences
c
BPD vs. ADHD significant differences
d
The mentioned percentages refer to 26 of the 29 patients with BPD. For the remaining 3 BPD patients information regarding the medication (whether
medication-free or intake was stopped 2 week prior to the study) was either missing or not entirely conclusive retrospectively.
were listed in Table 1. In all ADHD scales, ADHD
patients showed highest scores.
Manipulation check: Stress induction
Means with SD and statistics for subjective stress ratings
and heart rate are depicted in Table 2. The rm-ANOVA
with heart rate as dependent variable revealed a significant main effect of Condition (F(1,82) = 134.81, p ≤ .001,
η2p = 0.62), with significantly increased heart rates after
stress induction in all three groups. In the rm-ANOVA
for subjective stress, also a significant main effect of
Condition was found (F(1,84) = 86.51, p ≤ .001, η2p = 0.51),
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:6
Page 6 of 13
Table 2 Ratings of subjective stress and heart rate in resting condition and stress condition in healthy controls (HC), patients with
Borderline Personality Disorder (BPD) and patients with Attention Deficit Hyperactivity Disorder (ADHD)
Stress ratings M ± S.D.
Paired t-tests
Heart rate M ± S.D.
Paired t-tests
Resting condition
Stress condition
Resting condition
Stress condition
HC (n = 30)
1.63 ± 1.47
4.33 ± 2.20
t(29) = −6.50
p ≤ .001
d = 1.44
79.48 ± 11.43
101.10 ± 19.63
t(29) = −6.69
p ≤ .001
d = 1.35
BPDa (n = 29)
3.76 ± 1.70
5.72 ± 2.17
t(28) = −4.10
p ≤ .001
d = 1.01
80.96 ± 10.54
97.74 ± 16.92
t(26) = −7.53
p ≤ .001
d = 1.19
ADHD (n = 28)
3.50 ± 2.25
6.79 ± 1.89
t(27) = −5.65
p ≤ .001
d = 1.58
80.53 ± 13.60
93.57 ± 17.07
t(27) = −6.89
p ≤ .001
d = 0.85
ANOVA
F(2, 84) = 11.86
p ≤ .001b,c
η2p = 0.22
F(2, 84) = 10.00
p ≤ .001b,c
η2p = 0.19
F(2, 82) < 1
p = .939
F(2, 82) = 1.27
p = .285
Note: a = heart rate data of two BPD patients are missing due to technical problems (n = 27)
b
HC vs. BPD significant differences
c
HC vs. ADHD significant differences
indicating significantly higher subjective stress in the
stress condition. Furthermore, there was a significant
main effect of Group (F(1,84) = 18.38, p ≤ .001, η2p = 0.30),
with both patient groups reporting higher stress levels
than HCs under both conditions, but no significant
interaction effect (F(2,84) = 1.77, p = .177).
Self-reported trait anger and aggression
Table 3 presents the means with SD and statistics of the
STAXI, BPAQ and BGLHA subscales and total scales,
which were completed by the participants once within
the frames of the diagnostic procedure. Univariate ANOVAs using the total scores of the STAXI, BPAQ and
BGLHA as dependent variables revealed a significant
main effect of Group. For every score, post-hoc tests
showed significant differences between BPD and HC (all
p ≤ .001), as well as between ADHD and HC (all
p ≤ .001), with higher scores in BPD and ADHD patients
than in HCs. Compared to ADHD patients, BPD patients also showed significantly higher ratings in the
BPAQ total score (p = .020). MANOVAs with the STAXI
subscales “temperament” and “reaction” (F(4,166) = 16.09,
p ≤ .001, η2p = 0.28) and the three expression scales “anger
in”, “anger out” and “anger control” (F(6,164) = 21.55,
p ≤ .001, η2p = 0.44) also showed significant effects of
group. Post-hoc analyses revealed that both BPD and
ADHD patients scored higher on the temperament,
reaction, anger in and anger out scales and lower on the
anger control scale than HCs (all p ≤ .001, except HC vs.
BPD in STAXI control p = .002). Group differences
between BPD and ADHD were also significant in the
reaction (p = .024) and anger in scale (p ≤ .001), with
BPD patients reporting higher scores.
There was a main effect of group in the MANOVAs
for the BPAQ subscales anger, hostility, physical and
verbal aggression (F(8,162) = 16.98, p ≤ .001, η2p = 0.46).
Post-hoc analyses revealed that BPD and ADHD patients
both rated themselves significantly higher on all four
subscales compared to HCs (all p ≤ .001, except HC vs.
BPD for verbal aggression: p = .007; HC vs. ADHD for
verbal aggression: p = .021 and physical aggression: p
= .010). Furthermore, patient groups differed from each
other on the hostility subscale, with BPD patients reporting more hostility than ADHD patients (p ≤ .001).
Self-reported state anger
Figure 1 shows the means with standard errors of STAXI
state scores under resting and stress conditions. The rmANOVA revealed a significant main effect of condition
(F(1,84) = 5.49, p = .022, η2p = 0.06), a main effect of group
(F(2,84) = 23.72, p ≤ .001, η2p = 0.36), as well as a significant
condition x group interaction effect (F(2,84) = 4.39, p
= .015, η2p = 0.10). BPD patients showed higher state
anger compared to HC and compared to ADHD patients
under both conditions (all: p ≤ .001). An increase of state
anger after stress induction was significant in BPD
patients (p = .021), but not in HCs and ADHD patients.
Behavioral aggression
Means with standard errors of B button presses in the
PSAP under resting and stress conditions of all three
groups are shown in Fig. 2. The rm-ANCOVA for B button presses revealed no significant effects: main effect of
condition (F(1,84) =0.99, p = .323, η2p = 0.01), main effect of
group (F(1,84) =1.66, p = .197, η2p = 0.04), and condition x
group interaction effect (F(1,84) =0.04, p = .958, η2p < 0.01).
At the end of the whole study participants were asked
if they believed they had been playing with a real person.
As there have been suggestions that the validity of the
PSAP depends on the credibility of the cover story, we
also conducted a rm-ANOVA only with those participants who believe the cover story. This sample was
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:6
Page 7 of 13
Table 3 Means and standard deviation of STAXI, BPAQ and BGLHA scores and results of the univariate ANOVAs (F-ratio, p-value and
effect size) in healthy controls (HC), patients with Borderline Personality Disorder (BPD) and patients with Attention Deficit
Hyperactivity Disorder (ADHD)
HC (n = 30) M ± S.D.
BPD (n = 29)
M ± S.D.
ADHD (n = 28)
M ± S.D.
F
p
η2p
Total b,c
16.23 ± 3.53
29.52 ± 7.26
25.75 ± 6.96
37.00
≤.001
.47
Temperament b,c
7.43 ± 1.85
13.93 ± 4.51
12.43 ± 3.86
26.80
≤.001
.39
Trait measures
STAXI
Reaction
b,c,d
8.80 ± 2.31
15.59 ± 3.38
13.32 ± 3.77
34.55
≤.001
.45
Anger in
b,c,d
12.53 ± 3.37
23.72 ± 5.01
18.25 ± 5.36
42.95
≤.001
.51
b,c
11.30 ± 2.60
18.69 ± 6.22
18.79 ± 4.63
24.59
≤.001
.37
23.90 ± 4.40
19.86 ± 5.19
17.32 ± 3.36
16.62
≤.001
.28
Total b,c,d
44.97 ± 8.74
74.48 ± 14.98
64.93 ± 14.95
38.77
≤.001
.48
b,c
12.30 ± 3.57
19.17 ± 4.37
19.71 ± 4.71
28.12
≤.001
.40
11.03 ± 2.48
18.55 ± 7.45
15.57 ± 6.25
12.76
≤.001
.23
Anger out
Anger control b,c
BPAQ
Anger
Physical
Verbal
b,c
b,c
Hostility b,c,d
9.57 ± 2.00
12.31 ± 4.23
12.00 ± 3.62
5.78
.004
.12
12.07 ± 3.86
24.45 ± 5.12
17.64 ± 5.43
48.51
≤.001
.54
1.23 ± 1.94
10.48 ± 7.23
7.85 ± 4.66
26.01
≤.001
.39
a
BGLHA
Total b,c
Note: STAXI State-Trait Anger Expression Inventory, BPAQ Buss Perry Aggression Questionnaire, BGLHA Brown-Goodwin Lifetime History of Aggression
a
BGLHA: smaller sample size due to missing values: BPD (n = 27) and ADHD (n = 27)
b
HC vs. BPD significant differences
c
HC vs. ADHD significant differences
d
BPD vs. ADHD significant differences
composed of 21 HCs, 20 BPD patients and 21 ADHD
patients. Similar to the results when analysing the whole
sample no significant effects were found: main effect of
condition (F(1,59) =0.53, p = .471, η2p = 0.01), main effect
of group (F(1,59) =0.59, p = .557, η2p = 0.02), and condition
x group interaction effect (F(1,59) =0.49, p = .615, η2p =
0.02). See Additional file 2 for means and standard deviation of PSAP B button presses in the reduced sample.
Fig. 1 Means with standard errors of self-reported state anger
(STAXI) under resting and stress conditions in healthy controls (HC),
patients with Borderline Personality Disorder (BPD) and patients with
Attention Deficit Hyperactivity Disorder (ADHD)
Correlation analyses between anger, aggression and
emotion regulation capacities
In the BPD sample, a significant negative correlation
was found between the DERS score (emotion regulation)
and the STAXI total score (anger) (r = −0.614, p ≤ .001),
as well as the BPAQ total score (aggression) (r = −0.476,
p = .009). (Bonferroni correction: α’ = 0.017). There was a
Fig. 2 Means with standard errors of behavioural aggression (B button
presses in the PSAP) under resting and stress conditions in healthy
controls (HC), patients with Borderline Personality Disorder (BPD) and
patients with Attention Deficit Hyperactivity Disorder (ADHD)
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:6
trend for a correlations between the DERS total score
and the BGLHA in BPD patients (p = 0.061). In the
ADHD group, the correlation between DERS and BPAQ
as well as BGLHA did not reach significance. The
correlation with the STAXI scores did not survive
Bonferroni correction.
Discussion
We examined the impact of stress on self-reported and
behavioral measures of anger and aggression in female
patients with BPD, patients with ADHD and healthy
control participants.
The main findings of our study with female participants were: 1) higher self-appraisals of trait anger and
aggression in BPD and ADHD patients, 2) higher levels
of inwardly directed anger, anger when provoked, general aggression and hostility in BPD patients compared
to ADHD patients and 3) a stress-dependence of subjective angry states, but not behavioral aggression, in
BPD patients.
Self-reported trait anger and aggression
Patients reported significantly higher trait anger, anger
expression, aggressive and antisocial behavior compared
to HCs. These results are consistent with our hypothesis
and support previous studies investigating anger and aggression in BPD [18–20, 24, 37, 38] and ADHD patients
[32]. Both female patient groups reported to experience
more anger, regardless of provocation, compared to
HCs. This suggests that lower levels of provocation are
needed to evoke subjective anger in BPD and ADHD patients compared to HCs (STAXI “temperament”) and
that there is a higher sensitivity towards criticism and
rejection in these patients (STAXI “reaction”). This
sensitivity to provocation was significantly more pronounced in BPD patients compared to ADHD patients.
Furthermore, both patient groups showed a stronger
tendency to suppress feelings of anger, but also to express
anger toward other people and/or objects. These are not
mutually exclusive ways of anger expression. Whether
anger is directed inwardly or outwardly depends on aspects such as the situation, the circumstances or the status
of the present persons at the moment of annoyance [35].
Regarding anger expression, individuals may undergo a
consecutive process characterized by an initially strong
tendency to direct their anger inwardly, until a certain
threshold is reached and anger control breaks down, ending up in temper tantrums, throwing objects and/or acting
out violently towards others [70]. The intensity of this “belated” externalized anger may be stronger than in cases of
immediate outwardly directed anger. In line with the latter
findings, BPD and ADHD females rated their anger
control capacity lower than HCs. A difference between patients in anger expression was also found in the current
Page 8 of 13
study, as female BPD patients displayed a stronger tendency to direct their anger inwardly compared to female
ADHD patients. This tendency is probably related to selfdestructive behavior (e.g., self-injurious behavior, substance abuse), which is highly prevalent in BPD patients
(69–90%; [3, 71, 72]). Research has demonstrated that individuals with BPD are highly sensitive to social rejection
[73, 74]. Therefore, even if there is an external origin of
annoyance, the tendency to direct their anger mainly
inwardly or against themselves may be driven by the fear
of abandonment or rejection, if they were to direct their
aggression towards another person.
Ratings of aggression in the BPAQ also revealed higher
scores in patients concerning general aggression, as well
as the components of anger, hostility, verbal and physical
aggression. These findings are consistent with previous
studies [18, 19, 37]. Moreover, female BPD patients perceived themselves as generally more aggressive and hostile
than female ADHD patients. Hostility is an aspect of
aggression concerning suspiciousness and the critical appraisal of others and their behavior, which is a prominent
interpersonal problem in BPD patients [75, 76]. Furthermore, female and male patients reported that they were
more frequently involved in aggressive and antisocial acts
(e.g., fighting, assaults) than HCs (BGLHA).
In the present study, BPD patients reported to have
more difficulties in emotion regulation compared to HCs
and ADHD patients. An elevated self-reported proneness
to anger and aggression was significantly associated with
deficient emotion regulation capacities in this patient
group. Since correlational data do not allowed conclusions
about causality, it remains unclear whether enhanced trait
anger and aggression impede the acquisition of emotion
regulation capacities, or whether deficient emotion regulation skills promote anger experience and aggression.
Further studies using for example longitudinal designs (i.e.
applying emotion regulation training) are needed for the
clarification of this issue.
Self-reported state anger
Female BPD patients already perceived higher levels of
current anger feelings compared to ADHD patients and
HCs under resting conditions (STAXI state). After stress
induction, female BPD patients reported more anger,
whereas no change was observed in ADHD patients and
HCs. In male participants, anger feelings also did not
change significantly after stress induction. These results
suggest that self-perceived anger in female patients with
BPD is aggravated by stress.
Behavioral aggression
While most previous studies found significantly more B
button presses in the PSAP in BPD patients [18, 19, 37],
female patients in the present study did not make more
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:6
aggressive responses compared to HCs. After stress induction, we did not observe a stress-dependent change
in female patients. One possible explanation for the differing findings might be the presence of a camera in our
version of the PSAP, which may have enhanced the selfawareness of the participants. Previous research provides
indications for a relationship between higher selfawareness (e.g., presence of a camera) and behaving in a
less aggressive manner [77, 78]. There is also evidence
suggesting that high emotional awareness enables individuals to behave in an adaptive manner when experiencing negative emotional states [79]. The awareness of
one’s current emotional state in our study was possibly
enhanced by the questionnaires on tension and anger.
Due to the fact that we modified the PSAP our results
are not completely comparable to other findings with
older versions of the PSAP. For example, we did not find
increased levels of behavioral aggression in BPD patients
(under baseline conditions) such as New and colleagues
[18], McCloskey and colleagues [19] or Dougherty and
colleagues [37]. The comparability of the results is further
impeded by characteristics of the examined samples. For
example, New and colleagues [18] examined BPD patients
with comorbid intermittent explosive disorder and
Dougherty and colleagues [37] did not exclude bipolar
disorder and alcohol abuse. These comorbidities could at
least partly influence aggression proneness in BPD.
As one of our objectives was to control for the influence of ADHD symptoms in patients with BPD, we collected a sample of BPD patients without co-morbid
ADHD diagnosis. In clinical samples of BPD patients,
the presence of comorbid ADHD symptoms is very
likely [30, 40] and previous research indicates, that
impulse-control problems are more prominent in patients with the combined diagnosis of BPD and ADHD
[27, 32, 80]. Thus, the characteristics of our sample may
provide an explanation for our results. Future studies
should clarify whether there is a difference in the impact
of comorbid ADHD on aspects of impulse control in
female and male BPD patients.
Our self-report scales may also offer an explanation
why there was no elevated proneness to overt behavioral
aggression, since the results indicate that our female
BPD sample was characterized by a high tendency to
internalize their anger. Inwardly direct anger was significantly more pronounced in BPD patients than in ADHD
patients. However, we also did not observe an elevated level of behavioral aggression in our female
ADHD group. Previous results indicating elevated
proneness for aggression in ADHD patients have so
far been limited to children and adolescents [5, 7].
Longitudinal studies observing the development of
ADHD psychopathology revealed an age-dependent
decline of hyperactive and impulsive symptoms [81,
Page 9 of 13
82], which may also implicate a decline of aggressive
behavior over time [83].
Interestingly, only male patients in the pilot study
reacted more aggressively after stress induction, but no
significant changes in aggressive responding were observed in the female samples of the main study (and in
healthy males of the pilot study). Previous studies using
the PSAP have not revealed differences in the amount of
aggressive responses between men and women under
conditions without stress induction [18–20]. Whether
stress affects aggressive and antisocial behaviour patterns
differently in men and women has not been clarified in
these studies. There are assumptions that acute stress
may in fact enhance prosocial, rather than antisocial
behavior, mainly in women (“tend and befriend”; [84]).
However, in a recent study by von Dawans and colleagues [85] also healthy male participants showed an
improvement in prosocial behavior and unaffected antisocial behavior after stress exposure. Future studies
should further clarify the potential differential effects of
stress on aggressive behavior in larger samples of BPD
and ADHD males.
General discussion
Strengths of the current study are the moderate sample
of well-characterized and unmedicated participants and
the comparison of two clinical groups with a healthy
control group. In order to differentiate between BPD
and ADHD, participants underwent standardized diagnostics, which included structured interviews for BPD
(IPDE; [49]) and ADHD (WRAADDS; [59]), beyond selfrating symptom scales, and were conducted by experienced diagnosticians. Furthermore, our BPD patients,
ADHD patients and HCs did not differ in age and socioeconomic status. Although there were differences in
educational level, no group differences were found in a
measurement of intelligence (SPM), therefore, we
assumed all three groups had comparable cognitive
capacities.
However, some limitations have to be mentioned. It
seems important to consider that certain treatments of a
sufficient duration could affect symptom severity and
thus performance on the task. A special attribute of our
study was that all participants were unmedicated (but
not all drug-naive) and none of the participants was in
inpatient treatment as the investigation took place.
Regarding symptom severity, for example the BSL-23
scores indicate that we covered different relative symptom severities in the BPD sample, also including more
severely impaired patients (percentile ranks ranged from
14 to 79 in the BPD sample, mean = 51). However, in
future studies addressing anger and aggression the treatment history of patients should be assessed in detail.
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:6
Page 10 of 13
A critical point might be the type of aggression and
the duration of the provocation in the PSAP. Probably
penalizing a putative unknown opponent does not represent the type of explosive aggression described in BPD.
In BPD patients aggressive behavior in a relational context appears to be of importance as BPD is characterized
by chronic interpersonal conflicts [86–88]. Regarding
stress induction it should be considered that stress can
have different forms. For example stressors which are
emphasizing more relational aspects (i.e. Yale InterPersonal Stressor (YIPS); [89]) and induce feelings of exclusion and rejection can also increase self-reported stress
and physiological markers such as blood pressure, heart
rate and cortisol level [89]. Another approach considers
personal/individualized adverse factors such as negative
self-descriptions, stressful life-events or trauma-related
scripts [90, 91]. Further, as the duration of a stressor
seems relevant. As the PSAP performance took 12.5 minutes, there remains the question whether the procedure
provokes stress with a lasting effect (for more details see
Additional file 3).
As there is evidence for an association between
perimenstrual symptomatology and aggressive behavior
[92, 93], it is seen as a limitation that we did not control
for menstrual cycle, perimenstrual affective symptomatology or hormonal contraception in this study. Further interaction effects between hormonal contraception and stress
on prosocial and antisocial behavior are conceivable.
Although we excluded important comorbidities like
ADHD, substance abuse and bipolar disorder, we did not
exclude further comorbidities such as posttraumatic stress
disorder, which is highly prevalent in BPD patients [29, 94],
or antisocial personality disorder, which also frequently cooccurs in BPD [29, 95] and ADHD patients [96] and may
have an influence on patterns of anger and aggression.
Thus, the results of our study have to be interpreted with
caution given that there are further comorbidities that
could influence the findings. As comorbidity of BPD and
ADHD is high, the generalization of our results to clinical
samples may be difficult. Future studies should consider
adding a clinical sample of patients with BPD and comorbid ADHD, in order to directly examine possible
additive effects of the double diagnosis on anger and aggression. Overall, future research is needed to find differences between BPD and ADHD in order to improve
differential diagnosis and prevent treatment malpractice
(i.e. putting BPD patients on stimulants).
variables on dysfunctional behavior is important and can
help to adjust treatment strategies. In BPD patients, inwardly expressed anger appears to be pronounced. This
may be associated with aggressive self-destructive behavior
(e.g., self-injury) rather than overt aggressive behavior towards others. Providing functional strategies for anger
management seems substantial in the treatment of BPD,
even without co-occurring ADHD [97].
Conclusions
Deficits in impulse and anger control can lead to tantrums, assaults or physical fights and can cause severe
interpersonal and social problems. Even though aggressive
behavior is not necessarily intensified by stress, understanding the effects of stress and interaction with further
Funding
The study was supported by a grant from the German Research Foundation
(DFG) to GE and CS (EN 361/12-1 SCHM 1526/13-1).
Additional files
Additional file 1: Pilot study. Table S1. Demographic and clinical
variables in healthy control participants (HC) and patients with Borderline
Personality Disorder (BPD) or with Attention Deficit Hyperactivity Disorder
(ADHD) taken together. Table S2. Ratings of subjective stress and heart
rate in resting condition and stress condition in healthy controls (HC) and
patients with Borderline Personality Disorder (BPD) or with AttentionDeficit-Hyperactivity-Disorder (ADHD) taken together. Table S3. Means
and standard deviation of STAXI, BPAQ and BGLHA score results of
statistical group comparisons (student’s t-test, p-value and effect size) in
healthy controls (HC) and patients with Borderline Personality Disorder
(BPD) or with Attention-Deficit-Hyperactivity-Disorder (ADHD) taken
together. (DOCX 36 kb)
Additional file 2: PSAP subgroup analysis. Table S4. Means and
standard deviation of PSAP B button presses and statistical group
comparison (F-value of ANOVAs, p-value and effect size) in healthy
controls (HC) and patients with Borderline Personality Disorder (BPD) and
with Attention-Deficit-Hyperactivity-Disorder (ADHD) who believed the
PSAP cover story. (DOCX 21 kb)
Additional file 3: Lasting effect of stress induction. Table S5. Subjective
stress ratings under resting condition and after PSAP performance in the
stress condition and paired t-tests in HCs, BPD and ADHD patients.
(DOCX 17 kb)
Abbreviations
ADHD: Attention deficit hyperactivity disorder; ADHD-RS: Attention deficit
hyperactivity self-rating scale; ANOVA: Analyses of variance; BDI-II: Beck
Depression Inventory II; BIS-11: Barratt impulsiveness scale; BGLHA: BrownGoodwin lifetime history of aggression; BPAQ: Buss Perry aggression
questionnaire; BPD: Borderline personality disorder; BSL23: Borderline
symptoms list 23; CAARS-S:L: Connor adult ADHD rating scale - self report:
long version; CTQ: Childhood trauma-questionnaire; DERS: Difficulties in
emotion regulation scale; DES: Dissociative experiences scale;
IPDE: International personality disorder examination; MANOVA: Multivariate
ANOVA; MDD: Major depressive disorder; OCD: Obsessive compulsive
disorder; PFI: Provocation free interval (in the PSAP); PSAP: Point subtraction
aggression paradigm; PTSD: Posttraumatic stress disorder; rmANOVA: Repeated measure ANOVA; SCID-I: Structural clinical interview for
DSM-IV; STAXI: State-trait anger expression inventory; WRAADDS: WenderReimherr adult attention deficit disorder scale; WURS-k: Wender Utah rating
scale short version
Acknowledgements
We thank Alexandra Philipsen for help in patient recruitment. Further, we
thank all participants for their collaboration in this study.
Availability of data and materials
The dataset supporting the conclusions of this article is available on request
to Sylvia Cackowski (sylvia.cackowski@zi-mannheim.de).
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:6
Authors’ contributions
SC drafted the manuscript, conducted the analysis and led the interpretation
of the data. AK, GE and ES made substantial contributions to the manuscript
conceptualizing and its revision. JV and SD designed and programmed the
applied version of the PSAP. SC, SD and KK conducted the investigation. All
authors approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
This study was approved by the Ethics committee of the Medical Faculty
Mannheim/Heidel-berg University and was conducted in accordance with
the Declaration of Helsinki. The procedure of the study was explained in
detail and a written informed consent was signed by all participants.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Psychosomatic Medicine and Psychotherapy, Central
Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg
University, J5, D-68159 Mannheim, Germany. 2Department of Clinical
Psychology, Faculty of Social and Behavioural Science, Leiden University,
Leiden, The Netherlands. 3Department of Neuroimaging, Central Institute of
Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim,
Germany. 4Department of Psychiatry and Psychotherapy, Central Institute of
Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim,
Germany.
Received: 25 November 2016 Accepted: 10 March 2017
References
1. Leichsenring F, Leibing E, Kruse J, New A, Leweke F. Borderline personality
disorder. Lancet. 2011;377:74–84.
2. Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline
personality disorder. Lancet. 2004;364:453–61.
3. Skodol AE, Gunderson JG, Pfohl B, Widiger TA, Livesley WJ, Siever LJ. The
borderline diagnosis I: Psychopathology comorbidity, and personaltity
structure. Biol Psychiatry. 2002;51:936–50.
4. Barkley RA. Behavioral inhibition, sustained attention, and executive
functions: Constructing a unifying theory of ADHD. Psychol Bull.
1997;121:65–94.
5. Connor DF, Chartier KG, Preen EC, Kaplan RF. Impulsive aggression in
attention-deficit/hyperactivity disorder: Symptom severity, co-morbidity, and
attention-deficit/hyperactivity disorder subtype. J Child Adolesc
Psychopharmacol. 2010;20:119–26.
6. Harty SC, Miller CJ, Newcorn JH, Halperin JM. Adolescents with childhood
ADHD and comorbid disruptive behavior disorders: Aggression, anger, and
hostility. Child Psychiatry Hum Dev. 2009;40:85–97.
7. Jensen PS, Youngstrom EA, Steiner H, Findling RL, Meyer RE, Malone RP, et
al. Consensus report on impulsive aggression as a symptom across
diagnostic categories in child psychiatry: Implications for medication
studies. J Am Acad Child Adolesc Psychiatry. 2007;46:309–22.
8. Latalova K, Prasko J. Aggression in borderline personality disorder. Psychiatr
Q. 2010;81:239–51.
9. Ross JM, Babcock JC. Proactive and reactive violence among intimate
partner violent men diagnosed with antisocial and borderline personality
disorder. J Fam Violence. 2009;24:607–17.
10. Carré JM, McCormick CM, Hariri AR. The social neuroendocrinology of
human aggression. Psychoneuroendocrinology. 2011;36:935–44.
11. Anderson CA, Bushman BJ. Human aggression. Annu Rev Psychol.
2002;53:27–51.
12. Archer J. Sex differences in aggression in real-world settings: A metaanalytic review. Rev Gen Psychol. 2004;8:291–322.
Page 11 of 13
13. Bettencourt BA, Miller N. Gender differences in aggression as a function of
provocation: A meta-analysis. Psychol Bull. 1996;119:422–47.
14. Elbogen EB, Johnson SC. The intricate link between violence and mental
disorder: Results from the national epidemiologic survey on alcohol and
related conditions. Arch Gen Psychiatry. 2009;66:152–61.
15. Fossati A, Barratt ES, Borroni S, Villa D, Grazioli F, Maffei C. Impulsivity,
aggressiveness, and DSM-IV personality disorders. Psychiatry Res. 2007;149:157–67.
16. Gowin JL, Green CE, Alcorn III JL, Swann AC, Moeller FG, Lane SD. The role
of cortisol and psychopathy in the cycle of violence. Psychopharmacology.
2013;227:661–72.
17. Hammock GS, Richardson DR. Predictors of aggressive behavior. Aggr
Behav. 1992;18:219–29.
18. New AS, Hazlett EA, Newmark RE, Zhang J, Triebwasser J, Meyerson D, et al.
Laboratory induced aggression: A positron emission tomography study of
aggressive individuals with borderline personality disorder. Biol Psychiatry.
2009;66:1107–14.
19. McCloskey MS, New AS, Siever LJ, Goodman M, Koenigsberg HW, Flory JD, et al.
Evaluation of behavioral impulsivity and aggression tasks as endophenotypes for
borderline personality disorder. J Psychiatr Res. 2009;43:1036–48.
20. Perez-Rodriguez MM, Hazlett EA, Rich EL, Ripoll LH, Weiner DM, Spence N, et al.
Striatal activity in borderline personality disorder with comorbid intermittent
explosive disorder: Sex differences. J Psychiatr Res. 2012;46:797–804.
21. Berkowitz L. Aggression: Its causes, consequences, and control. New York:
Mcgraw-Hill; 1993.
22. Stiglmayr CE, Grathwol T, Linehan MM, Ihorst G, Fahrenberg J, Bohus M.
Aversive tension in patients with borderline personality disorder: A computerbased controlled field study. Acta Psychiatr Scand. 2005;111:372–9.
23. Stiglmayr CE, Bischkopf J, Albrecht V, Porzig N, Scheuer S, Lammers C, et al.
The experience of tension in patients with borderline personality disorder
compared to other patient groups and healthy controls. J Soc Clin Psychol.
2008;27:425–46.
24. Cackowski S, Reitz AC, Ende G, Kleindienst N, Bohus M, Schmahl C, et al.
Impact of stress on different components of impulsivity in borderline
personality disorder. Psychol Med. 2014;44:3329–40.
25. Chapman AL, Leung DW, Lynch TR. Impulsivity and emotion dysregulation
in borderline personality disorder. J Pers Assess. 2008;22:148–64.
26. Domes G, Winter B, Schnell K, Vohs K, Fast K, Herpertz SC. The influence of
emotions on inhibitory functioning in borderline personality disorder.
Psychol Med. 2006;36:1163–72.
27. Krause-Utz A, Sobanski E, Alm B, Valerius G, Kleindienst N, Bohus M, et al.
Impulsivity in relation to stress in patients with borderline personality
disorder with and without co-occurring attention-deficit/hyperactivity
disorder: An exploratory study. J Nerv Ment Dis. 2013;201:116–23.
28. Fossati A, Novella L, Donati D, Donini M, Maffei C. History of childhood
attention deficit/hyperactivity disorder symptoms and borderline personality
disorder: A controlled study. Compr Psychiatry. 2002;43:369–77.
29. Grant BF, Chou SP, Goldstein RB, Huang B, Stinson FS, Saha TD, et al.
Prevalence, correlates, disability, and comorbidity of DSM-IV borderline
personality disorder: Results from the Wave 2 National Epidemiologic
Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2008;69:533–45.
30. Philipsen A, Limberger MF, Lieb K, Feige B, Kleindienst N, Ebner-Priemer U,
et al. Attention-deficit hyperactivity disorder as a potentially aggravating
factor in borderline personality disorder. Br J Psychiatry. 2008;192:118–23.
31. Dowson JH, Blackwell AD. Impulsive aggression in adults with attentiondeficit/hyperactivity disorder. Acta Psychiatr Scand. 2010;121:103–10.
32. Lampe K, Konrad K, Kroener S, Fast K, Kunert HJ, Herpertz SC.
Neuropsychological and behavioural disinhibition in adult ADHD compared
to borderline personality disorder. Psychol Med. 2007;37:1717–29.
33. Latalova K. Bipolar disorder and aggression. Int J Clin Pract. 2009;63:889–99.
34. Swanson JW, Holzer III CE, Ganju VK, Jono RT. Violence and psychiatric
disorder in the community: Evidence from the Epidemiologic Catchment
Area Surveys. Hosp Community Psychiatry. 1990;41:761–70.
35. Schwenkmezger P, Hodapp V, Spielberger C. The State-Trait Anger
Expression Inventory. Goettingen: Huber; 1992
36. Buss AH, Perry M. The aggression questionnaire. J Pers Soc Psychol. 1992;63:452–9.
37. Dougherty DM, Bjork JM, Huckabee HC, Moeller FG, Swann AC. Laboratory
measures of aggression and impulsivity in women with borderline
personality disorder. Psychiatry Res. 1999;85:315–26.
38. Gardner DL, Leibenluft E, O’Leary KM, Cowdry RW. Self-ratings of anger and
hostility in borderline personality disorder. J Nerv Ment Dis.
1991;179:157–61.
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:6
39. Cherek DR, Lane SD, Pietras CJ. Laboratory measures of aggression: Point
Subtraction Aggression Paradigm (PSAP). In: Coccaro EF, editor. Aggression:
Assessment and treatment into the 21st century. New York: Marcel Dekker;
2003. p. 215–28.
40. Ferrer M, Andion O, Matali J, Valero S, Navarro JA, Ramos-Quiroga JA, et al.
Comorbid attention-deficit/hyperactivity disorder in borderline patients
defines an impulsive subtype of borderline personality disorder. J Pers
Disord. 2010;24:812–22.
41. Prada P, Hasler R, Baud P, Bednarz G, Ardu S, Krejci I, et al. Distinguishing
borderline personality disorder from adult attention deficit/hyperactivity disorder:
A clinical and dimensional perspective. Psychiatry Res. 2014;217:107–14.
42. Ramirez CA, Rosén LA, Deffenbacher JL, Hurst H, Nicoletta C, Rosencranz T,
et al. Anger and anger expression in adults with high ADHD symptoms. J
Atten Disord. 1997;2:115–28.
43. Hervey AS, Epstein JN, Curry JF. Neuropsychology of adults with attentiondeficit/hyperactivity disorder: A meta-analytic review. Neuropsychology.
2004;18:485–503.
44. Lijffijt M, Kenemans JL, Verbaten MN, van Engeland H. A meta-analytic
review of stopping performance in attention-deficit/hyperactivity disorder:
Deficient inhibitory motor control? J Abnorm Psychol. 2005;114:216–22.
45. Casat CD, Pearson DA, Van Davelaar MJ, Cherek DR. Methylphenidate effects
on a laboratory aggression measure in children with ADHD.
Psychopharmacol Bull. 1995;31:353–6.
46. Murphy DA, Pelham WE, Lang AR. Aggression in boys with attention deficithyperactivity disorder: Methylphenidate effects on naturalistically observed
aggression, response to provocation, and social information processing. J
Abnorm Child Psychol. 1992;20:451–66.
47. Pelham WE, Milich R, Cummings EM, Murphy DA, Schaughency EA, Greiner
AR. Effects of background anger, provocation, and methylphenidate on
emotional arousal and aggressive responding in attention-deficit
hyperactivity disordered boys with and without concurrent aggressiveness.
J Abnorm Child Psychol. 1991;19:407–26.
48. First MB, Spitzer RL, Gibbon M, Williams JBW, Benjamin LS. User's guide for
the structured clinical interview for DSM-IV Axis I disorders (SCID-I) - clinical
version. Washington: American Psychiatric Press; 1997.
49. Loranger AW. International Personality Disorder Examination (IPDE): DSM-IV
and ICD-10 modules. Odessa: Psychological Assessment Resources; 1999.
50. Raven J, Raven JC, Court JH. Raven’s progressive matrices und vocabulary
scales. Frankfurt: Pearson Assessment; 2003.
51. Bohus M, Kleindienst N, Limberger MF, Stieglitz R-D, Domsalla M, Chapman
AL, et al. The short version of the Borderline Symptom List (BSL-23):
Development and initial data on psychometric properties. Psychopathology.
2009;42:32–9.
52. Beck AT, Steer RA, Ball R, Ranieri W. Comparison of Beck Depression Inventories
-IA and -II in psychiatric outpatients. J Pers Assess. 1996;67:588–97.
53. Patton JH, Stanford MS, Barratt ES. Factor structure of the Barratt
Impulsiveness Scale. J Clin Psychol. 1995;51:768–74.
54. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and
dysregulation: Development, factor structure, and initial validation of the Difficulties
in Emotion Regulation Scale. J Psychopathol Behav Assess. 2004;26:41–54.
55. Retz-Junginger P, Retz W, Blocher D, Stieglitz RD, Georg T, Supprian T, et al.
Reliability and validity of the Wender-Utah-Rating-Scale short form.
Retrospective assessment of symptoms for attention deficit/hyperactivity
disorder. Nervenarzt. 2003;74:987–93.
56. Rösler M, Retz W, Retz-Junginger P, Thome J, Supprian T, Nissen T, et al.
Tools for the diagnosis of attention-deficit/hyperactivity disorder in adults.
Self-rating behaviour questionnaire and diagnostic checklist. Nervenarzt.
2004;75:888–95.
57. Christiansen H, Kis B, Hirsch O, Matthies S, Hebebrand J, Uekermann J, et al.
German validation of the Conners Adult ADHD Rating Scales (CAARS) II:
Reliability, validity, diagnostic sensitivity and specificity. Eur Psychiatry. 2012;
27:321–8.
58. American Psychiatric Association (APA). Diagnostic and Statistical Manual of
Mental Disorders. 4th ed. Washington: American Psychiatric Association;
2000.
59. Rösler M, Retz W, Retz-Junginger P, Stieglitz RD, Kessler H, Reimherr F, et al.
Attention deficit hyperactivity disorder in adults. Benchmarking diagnosis
using the Wender-Reimherr Adult Rating Scale. Nervenarzt. 2008;79:320–7.
60. Brown GL, Goodwin FK, Ballenger JC, Goyer PF, Major LF. Aggression in
humans correlates with cerebrospinal fluid amine metabolites. Psychiatry
Res. 1979;1:131–9.
Page 12 of 13
61. Marsh DM, Dougherty DM, Moeller FG, Swann AC, Spiga R. Laboratorymeasured aggressive behavior of women: Acute tryptophan depletion and
augmentation. Neuropsychopharmacology. 2002;26:60–671.
62. McCloskey MS, Berman ME, Coccaro EF. Providing an escape option reduces
retaliatory aggression. Aggress Behav. 2005;31:228–37.
63. Gallardo-Pujol D, Andrés-Pueyo A, Maydeu-Olivares A. MAOA genotype,
social exclusion and aggression: An experimental test of a geneenvironment interaction. Genes Brain Behav. 2013;12:140–5.
64. Cherek DR, Lane SD, Dougherty DM, Moeller FG, White S. Laboratory and
questionnaire measures of aggression among female parolees with violent
or nonviolent histories. Aggr Behav. 2000;26:291–307.
65. Geniole SN, Carré JM, McCormick CM. State, not trait, neuroendocrine
function predicts costly reactive aggression in men after social exclusion
and inclusion. Biol Psychol. 2011;87:137–45.
66. Kolotylova T, Koschke M, Bar KJ, Ebner-Priemer U, Kleindienst N, Bohus M, et
al. Development of the “Mannheim Multicomponent Stress Test” (MMST).
Psychother Psychosom Med Psychol. 2010;60:64–72.
67. Reinhardt T, Schmahl C, Wust S, Bohus M. Salivary cortisol, heart rate,
electrodermal activity and subjective stress responses to the Mannheim
Multicomponent Stress Test (MMST). Psychiatry Res. 2012;198:106–11.
68. Lejuez CW, Kahler CW, Brown RA. A modified computer version of the
Paced Auditory Serial Addition Task (PASAT) as a laboratory-based stressor.
The Behavior Therapist. 2003;26:290–3.
69. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed.
Hillsdale: Lawrence Erlbaum Associates; 1988.
70. Herpertz S, Sass H. Impulsiveness and impulse control. On the
psychological and psychopathological conceptualization. Nervenarzt.
1997;68:171–83.
71. Chapman AL, Gratz KL, Brown MZ. Solving the puzzle of deliberate selfharm: The experiential avoidance model. Behav Res Ther. 2006;44:371–94.
72. Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G, Weinberg I,
Gunderson JG. The 10-year course of physically self-destructive acts
reported by borderline patients and axis II comparison subjects. Acta
Psychiatr Scand. 2008;117:177–84.
73. Miano A, Fertuck EA, Arntz A, Stanley B. Rejection sensitivity is a mediator
between borderline personality disorder features and facial trust appraisal.
J Pers Disord. 2013;27:442–56.
74. Staebler K, Helbing E, Rosenbach C, Renneberg B. Rejection sensitivity
and borderline personality disorder. Clin Psychol Psychother. 2011;18:
275–83.
75. Gunderson JG. Disturbed relationships as a phenotype for borderline
personality disorder. Am J Psychiatry. 2007;164:1637–40.
76. Stanley B, Siever LJ. The interpersonal dimension of borderline personality
disorder: Toward a neuropeptide model. Am J Psychiatry. 2010;167:24–39.
77. Bailey D, Leonard K, Cranston J, Taylor S. Effects of alcohol and self-awareness
on human physical aggression. Pers Soc Psychol Bull. 1983;9:289–95.
78. Scheier M, Fenigstein A, Buss A. Self-awareness and physical aggression.
J Exp Soc Psychol. 1974;10:264–73.
79. Roberton T, Daffern M, Bucks RS. Emotion regulation and aggression.
Aggress Violent Behav. 2012;17:72–82.
80. Sebastian A, Jacob G, Lieb K, Tuscher O. Impulsivity in borderline personality
disorder: A matter of disturbed impulse control or a facet of emotional
dysregulation? Curr Psychiatry Rep. 2013;15:339.
81. Biederman J, Mick E, Faraone SV. Age-dependent decline of symptoms of
attention deficit hyperactivity disorder: Impact of remission definition and
symptom type. Am J Psychiatry. 2000;157:816–8.
82. Hart EL, Lahey BB, Loeber R, Applegate B, Frick PJ. Developmental change in
attention-deficit hyperactivity disorder in boys: A four-year longitudinal
study. J Abnorm Child Psychol. 1995;23:729–49.
83. Taylor E, Chadwick O, Heptinstall E, Danckaerts M. Hyperactivity and
conduct problems as risk factors for adolescent development. J Am Acad
Child Adolesc Psychiatry. 1996;35:1213–26.
84. Taylor SE. Tend and befriend biobehavioral bases of affiliation under stress.
Curr Dir Psychol Sci. 2006;15:273–7.
85. Dawans B, Fischbacher U, Kirschbaum C, Fehr E, Heinrichs M. The social
dimension of stress reactivity: Acute stress increases prosocial behavior in
humans. Psychol Sci. 2012;23:651–60.
86. Newhill CE, Eack SM, Mulvey EP. Violent behavior in borderline personality.
J Pers Disord. 2009;23:541–54.
87. Sansone RA, Sansone LA. Borderline Personality and Externalized
Aggression. Innov Clin Neurosci. 2012;9:23–6.
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:6
Page 13 of 13
88. Weinstein Y, Gleason ME, Oltmanns TF. Borderline but not antisocial
personality disorder symptoms predict self-reported partner aggression in
later life. J Abnorm Psychol. 2012;121:692–8.
89. Stroud LR, Tanofsky-Kraff M, Wilfley DE, Salovey P. The Yale Interpersonal
Stressor (YIPS): affective, physiological, and behavioral responses to a novel
interpersonal rejection paradigm. Ann Behav Med. 2000;22:204–13.
90. Schmahl C, Vermetten E, Bernet EM, Bremner JD. A positron emission
tomography study of memories of childhood abuse in borderline
personality disorder. Biol Psychiatry. 2004;55:759–65.
91. Wingenfeld K, Mensebach C, Rullkoetter N, Schlosser N, Schaffrath C,
Woermann FG, et al. Attentional bias to personally relevant words in
borderline personality disorder is strongly related to comorbid
posttraumatic stress disorder. J Pers Disord. 2009;23:141–55.
92. Dougherty DM, Bjork JM, Moeller FG, Swann AC. The influence of
menstrual-cycle phase on the relationship between testosterone and
aggression. Physiol Behav. 1997;62:431–5.
93. Dougherty DM, Bjork JM, Cherek DR, Moeller FG, Huang DB. Effects of
menstrual cycle phase on aggression measured in the laboratory. Aggr
Behav. 1998;24:9–26.
94. Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR. Axis I comorbidity
in patients with borderline personality disorder: 6-year follow-up and
prediction of time to remission. Am J Psychiatry. 2004;161:2108–14.
95. Zanarini MC, Frankenburg FR, Dubo ED, Sickel AE, Trikha A, Levin A, et al.
Axis II comorbidity of borderline personality disorder. Compr Psychiatry.
1998;39:296–302.
96. Torgersen T, Gjervan B, Rasmussen K. ADHD in adults: A study of clinical
characteristics, impairment and comorbidity. Nord J Psychiatry. 2006;60:38–43.
97. Linehan MM. Cognitive-behavioural treatment of borderline personality
disorder. New York: Guilford Press; 1993.
Submit your next manuscript to BioMed Central
and we will help you at every step:
• We accept pre-submission inquiries
• Our selector tool helps you to find the most relevant journal
• We provide round the clock customer support
• Convenient online submission
• Thorough peer review
• Inclusion in PubMed and all major indexing services
• Maximum visibility for your research
Submit your manuscript at
www.biomedcentral.com/submit