by Randy A. Sansone, MD, and Lori A. Sansone, MD

Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.

Psychiatry (Edgemont) 2010;7(9):16–20

Funding: There was no funding for the development and writing of this article.

Financial Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Key Words: Borderline personality, emotional responsiveness, reactivity, environmental stimuli

Abstract: According to clinical experience, the Diagnostic and Statistical Manual of Mental Disorders, and authorities in the field, patients with borderline personality disorder tend to be hyper-reactive to environmental stimuli. In addition to the preceding clinical impressions and experiences, the majority of empirical studies in this area have concluded that patients with borderline personality disorder are indeed hyper-responsive to experimental environmental stimuli, whether the stimuli are negative, positive, or even neutral or ambiguous. While two empirical studies did not find hyper-responsiveness, both were undertaken in inpatients with borderline personality disorder, and the potential for emotional blunting from psychotropic medications may have been a potential confound. These findings have several clinical implications in both mental health and primary care settings.


Borderline personality disorder (BPD) lies within the Cluster B personality grouping in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)[1] and is associated with the cluster characteristics of dramatic, emotional, and erratic personality features. In keeping with this description, patients with BPD are characterized as being emotionally labile and hyper-reactive. In this edition of The Interface, we will explore the feature of emotional hyper-reactivity in patients with BPD from the perspective of clinical experience as well as through evidence from empirical studies.

Clinical Experience with Emotional Hyper-Reactivity

Clinicians in both mental health settings and primary care settings are likely to have experienced the emotional hyper-reactivity of patients with BPD. These Axis II individuals appear to be exquisitely sensitive and responsive to both internal and external stimuli.[2] As we have previously described in patients with BPD, “…there is a heightened awareness and scanning of the external surroundings; this state of heightened external alertness may explain the seemingly exquisite interpersonal sensitivity of these patients…”[2] In our experience, the manifestation of emotional hyper-reactivity in patients with BPD appears to be particularly likely under two conditions: (1) the perception (or misperception) by the individual with BPD that a relationship is about to dissolve and (2) the experience of a limit (e.g., placing a limit on the amount of prescribed alprazolam or scheduled analgesics in a primary care setting). In these circumstances, the patient with BPD is likely to over-respond or over-react in an emotionally volatile, angry, and, at times, regressive manner.

Authorities in the field have repetitively portrayed the emotional hyper-reactivity of patients with BPD. For example, in the DSM-IV,[3] patients with BPD are described as being, “…very sensitive to environmental circumstances,” particularly, “the perception of impending separation or rejection.” Kroll indicates that, “borderlines [demonstrate an] intense focus and perseveration upon negative themes…,”[4] indicating that these patients tend to become preoccupied with dismal and melancholic subject matter. Seiver states that, “the borderline personality disordered individual appears to have a lower threshold to environmental stimuli, particularly frustrating stimuli…,” again indicating a hypersensitivity to provocative negative elements in the external environment.[5] This impression is in keeping with the views of Linehan and Heard, who emphasize that, “emotional vulnerability refers to the [borderline] individual’s greater responsiveness to emotionally evocative stimuli, a responsiveness that includes both frequent and intense responses to even low-intensity or subtle stimuli.”[6] The impression of these latter authors is particularly relevant because they indicate that patients with BPD may react to even “low-intensity” and “subtle” stimuli (i.e., the magnitude of the stimulus does not have to be very high). Linehan later reinforces this perspective by stating that the “characteristics of emotional vulnerability include high sensitivity to emotional stimuli…it does not take much to provoke an emotional reaction.”[7]

The preceding material underscores in patients with BPD the theme of hyper-reactivity in relationship to the environment. This hyper-reactivity is described as a sensitivity, a low threshold for responsiveness, and a greater responsiveness to the environment. Environmental elements are described to as low-level, subtle, negative, and emotionally evocative.

In addition to this evolving psychological picture, Brandchaft and Stolorow add that, “when the needs [of the borderline patient] are responded to, or understood and interpreted empathically, intense positive reactions occur; similarly, when these needs are not recognized, responded to, or interpreted empathetically, violent negative reactions may ensue.”[8] Importantly, this supplemental commentary indicates that in addition to negative environmental stimuli, patients with BPD may also over-respond to positive environmental stimuli. If so, then emotional hyper-reactivity may be characteristic of both negative and positive perceptions of stimuli in the environment. Given these impressions and conclusions, is there any empirical evidence?

Empirical Evidence for Emotional Hyper-Reactivity in BPD

Emotional over-responsiveness, which is fairly characteristic of BPD, is supported by several empirical studies. For example, Jennings[9] studied 19 undergraduate students with and 16 undergraduate students without BPD. She exposed them to evocative color slides, 42 each, of pleasant, neutral, and unpleasant themes. Compared with controls, undergraduate students with borderline personality characteristics showed significantly greater overall magnitudes of startle response regardless of the valence of the slide content. In other words, in this study, participants with borderline personality symptomatology over-reacted to positive, neutral, and negative environmental content, indicating a pan-responsiveness to environmental stimuli.

In another study, Korfine and Hooley10 presented participants, with and without BPD, with words of different emotional valences. Participants were then asked to forget the words (i.e., a directed forgetting paradigm). Compared with controls, participants with BPD recalled significantly more of the high-valent words from the “forget” condition (i.e., a sensitivity to negative environmental stimuli).

Herpertz et al[11] presented participants with a short story and monitored their affective responses to various stimuli with regard to quality, intensity, and alterations over time. These investigators found that those participants with BPD evidenced greater emotional hyper-reactivity as well as a lower threshold for emotional responses and rapidly changing intense affects.
Conrad and Morrow[12] examined 109 male college students’ responses to three videos. The videos were approximately 15 minutes long and contained distinctly different types of news items—neutral news reports, news reports depicting violence, and news reports based upon abandonment themes. As an example, in the third video segment, the content centered on the abandonment and rejection of children by parents or caregivers, such as the search for dead-beat fathers and an infant being left alone in a car at the racetrack. Compared with controls and participants with low borderline symptoms, participants with high levels of borderline personality symptomatology reported a significantly greater willingness to use verbal and/or symbolic aggression, including threats of violence, against a partner as well as actual violence against inanimate objects. In other words, they emotionally reacted more dramatically to viewing these videos.

Finally, using several tests, Domes et al[13] examined 28 unmedicated women with BPD and 30 control subjects. The investigators found that, compared with healthy controls, women with BPD had more difficulty suppressing irrelevant information of an aversive nature. Again, participants with BPD demonstrated a sensitivity to external negative stimuli.
The preceding studies support the clinical premise that individuals with BPD manifest an emotional hyper-reactiveness to environmental stimuli. According to the findings of Jennings,[9] this hyper-reactiveness may even extend beyond either positive or negative environmental stimuli, and include neutral environmental stimuli as well. In support of these findings, in a study of primary care patients, we found that, compared with controls, those with BPD uniquely over-reacted to neutral (ambiguous) environmental stimuli (in this case, hypothetical media events), but not to positive or to negative environmental stimuli.[14]

In contrast to the preceding studies, two outlier studies do not support the impression of environmental hyper-reactivity in patients with BPD. In the first, Renneberg et al[15] compared inpatients with BPD to inpatients with major depression and controls. These investigators found that when presented with two short video sequences depicting positive or negative emotions, compared with controls, participants with BPD demonstrated reduced facial expressiveness, which was akin to the response pattern observed in the depressed subsample. However, this finding may have been confounded by the presence of psychotropic medications in the BPD subsample, particularly sedating atypical antipsychotics16 and/or selective serotonin reuptake inhibitors,17 both of which may blunt emotional reactivity.

In the second outlier study, Herpertz et al[18] examined inpatients with BPD who were in a treatment program for severe personality disorders for a fixed time interval of 6 to 18 months. Investigators found that, upon viewing slides with various types of emotional content, participants with BPD did not demonstrate affective hyper-responsivity. Again, the type of psychotropic medications in this inpatient sample were not clarified by the authors, but may have played a contributory role to these atypical findings.

Summary of Findings and Clinical Implications

Clinical impressions, the DSM, descriptions by authorities in the field, and the bulk of empirical studies indicate that patients with BPD demonstrate a hyper-reactivity to environmental stimuli. Some data suggest that this hyper-reactivity is pronounced with negative environmental stimuli as well as positive environmental stimuli and even neutral or ambiguous stimuli. These findings imply that hyper-reactivity may develop in response to a variety of environmental contexts—i.e., a pan-hyper-responsiveness.

What do these findings mean to the clinician? First and foremost, patients with BPD are likely to be consistently hyper-reactive on an emotional level. Therefore, when encountering patients with this clinical feature, it is critically important to recognize that this phenomenon is part of the Axis II disorder—not necessarily an accurate reflection of the environment or the clinician’s behavior.

Second, these data indicate that in order for these individuals to effectively function in interpersonal relationships, this perceptual overdrive will require some therapeutic modification. Indeed, didactic instruction, skills development, and/or cognitive-behavioral approaches are evident in a number of interpersonal interventions for BPD.[19] For example, schema-focused therapy centers on cognitively restructuring longstanding schemas (i.e., enduring and stable dysfunctional themes that developed in childhood and are now maintained during adulthood), many of which relate to interpersonal themes. Dialectical behavior therapy incorporates education and skills acquisition in the area of interpersonal relationships. Systems training for emotional predictability and problem solving is based upon the regulation of emotional intensity, which is addressed through the development of an enhanced support network, skills acquisition, and cognitive-behavioral techniques. All of these approaches are intended to tame the emotional hyper-reactivity encountered in these challenging patients.

As for the primary care setting, clinicians need to be aware of the high likelihood of specific “negative stimuli” in the clinical setting that might induce over-responsitivity from patients with BPD. In this setting, negative stimuli are likely to include the experience of refusal (i.e., limit-setting). This may include refusal by the clinician to do a particular laboratory study (e.g., atypical or extensive and unnecessary studies), prescribe a particular medication (e.g., controlled substances, including analgesics, anxiolytics, appetite suppressants, and psychostimulants for purported attention-deficit hyperactivity disorder), and/or undertake a particular intervention (e.g., referring the patient for an unnecessary laparoscopy). In addition, refusal dynamics may emerge around patient requests for unnecessary time-off-work excuses, handicap flags for their vehicles, and requests for disability status. As well, patients with BPD may be exquisitely emotionally reactive to touch and physical examination, which may have connotations with negative experiences during childhood. In the presence of touch, borderline patients may become very emotional and regressive, particularly with invasive examinations. Again, clinicians in these settings need to anticipate emotional hyper-reactivity, prepare the patient if feasible by presenting medical stimuli in a impartial manner when possible, and avoid taking the patient’s response on a personal level.


According to clinical experience, the DSM, and a number of authorities in the field, patients with BPD are known to be emotionally hyper-reactive in various types of situations. In addition to the preceding observations, empirical studies indicate that patients with BPD may over-react to negative stimuli as well as positive stimuli. Some data even indicate that the individual may respond to neutral or ambiguous stimuli. These environmental situations, and their associated external stimuli, are typically related to relationship issues with themes of loss/abandonment and/or the encountering of limits. Understanding the association of these potential reactions is vital and necessary in dealing with these Axis II patients, whether in the mental health setting or the primary care setting.


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