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Music therapy and neuroscience; Interpersonal synchronization in borderline personality disorder

An examination of methodological variation in the investigation of interpersonal factors problematic to individuals living with borderline personality disorder.

Introduction


Borderline personality disorder is characterized as “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning in early adulthood and present in a variety of contexts” (American Psychiatric Association, 2000). This essay on methodological variation examines two specific ways scientists have recently investigated some of the underlying processes related to interpersonal relations and how they may function in individuals living with this diagnosis. The first paper (Impaired Maintenance of Interpersonal Synchronization in Musical Improvisations of Patients with Borderline Personality Disorder (Foubert, Collins & De Backer, 2017)) examines these processes through the lens of psychology and more specifically uses a psychologically based music therapy centred methodology to compare interpersonal synchronization with BPD and healthy individuals. The second paper (Oxytocin can hinder trust and cooperation in borderline personality disorder (Bartz et al., 2010)) uses a neuroscientific lens to investigate the role of the neuropeptide oxytocin (often inaccurately described as the ‘hormone of love’ in folk psychology) in trust, specifically within a version of a prisoners dilemma game structure. These contrasting methodologies highlight the wide variety of tools available to the realm of cognitive science for understanding complex interpersonal processes exhibited in human interaction. The essay begins with a description of the rationales, methodologies, results and discussions from each paper, followed by an examination of how the different studies may inform and support or contradict each other, concluding with a synthesis of what can be gleaned about how these studies can inform the cognitive scientist about the complex realm of human interaction.


Paper I

The first study, (Impaired Maintenance of Interpersonal Synchronization in Musical Improvisations of Patients with Borderline Personality Disorder) (Foubert, Collins & De Backer, 2017) was designed as such, because “the embodied context of the musical interaction makes it possible to study the automatic, preconscious behaviour within complex personal interactions” with “one of the contributions… (being) to provide more objective, empirical evidence of the playing habits and interpersonal behaviour of BPD patients” (Foubert, Collins & De Backer, 2017). Temporal Interpersonal synchronization (IPS) was the specific domain of enquiry within a musical improvisation context as this ecologically valid domain for joint action builds upon various other studies conducted with typical samples of the population in areas such as social cohesion, cooperation and bonding and attachment (Marsh et al,. 2009, Anshel & Kipper, 1998, Wiltermuth and Heath, 2009, Hove and Risen, 2009 and Wheatley et al., 2012).

Four predictions were made at the beginning of the study;

1. Poorer temporal IPS, represented by higher overall timing deviations for BPD patients compared to normal controls

2. More oscillations (e.g. more variability) in timing deviations between therapist and BPD patients compared to normal controls

3. Problems in maintaining and improving IPS between therapist and BPD individuals in the course of the joint improvisation compared to normal controls

4. More impulsivity (less inhibition) in the playing of BPD patients then normal controls


(Foubert, Collins & De Backer, 2017)

Music information retrieval (MIR) variables were used to “measure the presence and development of temporal IPS between the accompanist and participant, and to measure the presence of rhythmic motifs/patterns in participants playing (Foubert, Collins & De Backer, 2017) alongside logistic regression modelling with “MIR variables as independent variables, to predict whether a given participant is a patient or a control as well as to assess… predictions”. Twenty eight participants were recruited in total (16 with BPD and 12 controls) with (some of) the inclusion criteria requiring participants to be between twenty one and sixty years old and without ever participating in a music therapy session. The Goldsmith Musical Sophistication Index (Gold-MSI, Mullensiefen et al., 2014) was used as a “self report measure of musical sophistication to analyse the confounding influence of musical experiences” (Foubert, Collins & De Backer, 2017), the Beat Alignment Test (BAT, Iversen & Pattel, 2008) was used to test beat perception and the relationship structure questionnaire (ECR-R, Fraley et al., 2011) assessed the type of attachment each individual had.


Procedure

Each improvisation was conducted on a Yamaha MPX70 piano with a (blind to diagnosis) senior music therapist. The only instruction given to participants was to play on the white keys. ABA’ improvisational structure was used with the A and A’ sections serving as a warm-up and cool-down through the use of an E class phyrigian fifth bourdon at 80bpm by the accompanist “offering many possibilities for the development of a melody or a polyphonic elaboration by a participant” (Foubert, Collins & De Backer, 2017). The B section moved to the A class Aeolian mode (with one exception) and was more dynamic (usually speeding up) in order to promote the emerging interaction. This was divided into sections B1 and B2 for analysis. Manual beat tracking was conducted by the music therapist after the experiment and the Lisp MSCtylistic and Matlab PattDisc software packages (Collins, 2011) were then used to quantize and analyse the musical information with seven of the fifteen variables of the MIR being identified as relevant to IPS.


Results

Mean metric deviation (MD_m) was used as the main operational definition of asynchrony and of the seven variables identified, only Lag proportion in section B1 (LP_B1) was found to be significantly different between experimental subjects and controls. This correlated the likelihood of lagging behind the beat in B1 with being a control (AIC=37.16). Following a stepwise selection process, a logistic regression model resulted in the calculation of an MD_m_B1 - MD_m_B2 variable which described the behaviour of improvement in IPS across the B section. Positive vs negative scores on this variable related to increases or decreases in IPS across the section. This variable was found to be able to predict incidences of BPD in participants with an 82% success rate (AIC=28.8). This was seen as being a possibly relevant diagnostic tool for BPD. Separate analyses were conducted on the variable to test for the influence of medication, depression, musical capacity and general attachment style. Avoidance general attachment style was significantly correlated with an increase in MD_m_B1 - MD_m_B2 and a decrease for anxious general attachment style in BPD participants with no correlation noted for controls. This made up for 52% of the variance within BPD patients.

Of the four predictions made at the beginning of the experiment, only predictions three (BPD patients would have difficulty maintaining and improving IPS) and four (BPD patients would exhibit more impulsivity) were corroborated. Significant temporal IPS difficulties relating to timing deviations and the oscillations of these deviations were not clearly seen during the improvisations. “This suggests that differences in overall timing deviations and oscillations in temporal IPS in a joint improvisation are not related to BPD characteristics” (Foubert, Collins & De Backer, 2017). Maintaining and improving IPS over the course of the improvisation was shown to be a challenge for BPD individuals however resulting in the authors to speculate that “the underlying cognitive motor skills associated with anticipation and adaptation are hindered in their ability to regulate and facilitate improvements in temporal IPS when the attachment system is activated in BPD patients” (Foubert, Collins & De Backer, 2017), which seems “to support current theories about the relation between alterations in the brain reward system in BPD individuals, attachment and prediction error” (Friston, 2005, 2010; Atzil et al., 2011; Fonagy et al., 2011; Brown and Brune, 2012; Enzi et al., 2013; Herpertz and Bertsch, 2015 as cited in Foubert, Collins & De Backer, 2017).


Paper II

The second paper (Oxytocin can hinder trust and cooperation in borderline personality disorder) (Bartz et al., 2010)) compared the role of Oxytocin (shown to increase trust in the typical human population (Kosfeld et al., 2005; Theodoridou et al., 2009)) in trust behaviour between BPD patients and typical controls. Although interpersonal difficulties for BPD individuals are experienced most vividly within established relationships, research has shown that this can also appear in sustaining cooperation in other social interactions (King-Casas et al., 2008). One noted suggestion was that oxytocin (OXT) may heighten the sensitivity of individuals to social cues rather than simply promote trust (Samay-Tsoory et al., 2009) which may have contraindicative effects for BPD individuals depending on the social context. Concerns were also raised that “the OXT system may be dysregulated in BPD, and for this reason, may produce a differential response to exogeneous OXT” (Bartz et al., 2010).

The main research questions were to investigate “the effects of intranasal OXT on trust and cooperative behaviour in healthy adults and adults with BPD” and “whether individual differences in attachment anxiety and attachment avoidance moderate the effects of OXT on trust and pro-social behaviour” (Bartz et al., 2010). The study included a total of twenty seven individuals (fourteen individuals with BPD) with a mean age of thirty five. Controls were psychiatrically screened to ensure there were no underlying disorders.


Procedure

Before playing the game, participants completed the Experience in Close Relationship Scale (ECR, Brennan et al., 1998) and the Profile of Mood States (POMS, McNair et al., 1992). 40IU of intranasal OXT (Syntocinon, Novartis) or placebos were then administered at a ratio of 14:13. Thirty five minutes later, another POMS test was administered and the after a brief description and quiz to ensure everyone understood the rules, participants began to play three rounds of the Assurance Game (AG: Kollock, 1998). The main difference between the AG and the standard prisoners dilemma game was that the AG “locates the self-interest and interpersonal solution in the same mutual cooperation cell” (Bartz et al., 2010). Although participants were introduced to partners who they were told would be playing from another room, they in fact played against a computer who was programmed to pick the most trusting option in each of the three rounds. After each round, participants were quizzed on what strategies they believed their partners chose as well as which strategies they would have chosen if they knew their partner was trustworthy. Before beginning the next round, the strategies each party had picked were revealed.

The data were analysed using analysis of variance (ANOVA) to assess group differences “on mean trust, strategic response to partner hypothetical cooperation and cooperative behaviour across rounds” (Bartz et al., 2010). This was followed by regression analyses to examine the relationship between OXT and different attachment types, t-tests to analyse individual differences within the groups and slope analysis of the graphs to compare variables between experimental participants and controls.


Results

Although results did not reach statistical significance, ANOVA suggested that OXT disinhibited cooperation for BPD individuals and showed no increase in trust for controls contradicting previous findings although it was noted that this may be due to “ceiling effects of the AG” (Bartz et al., 2010). Regression analyses also suggested that OXT resulted in different trust reactions depending on attachment type for BPD individuals with actual cooperative behaviour increasing for low avoidance and decreasing for high avoidance within anxiously attached individuals. Interestingly for BPD participants there was “significantly less trusting expectations about their partner and were significantly more likely to defect in response to partner cooperation in a hypothetical scenario following intranasal OXT compared to placebo” (Bartz et al., 2010). This suggested the BPD patients enacted an irrational and hostile strategy as the hypothetical scenario and cooperative nature of the AG appeared to rule out self-protective mechanisms. These divergent effects “were primarily driven by the anxiously attached, rejection sensitive participants”. The fact that group differences had no significant effects but individual differences did highlighted the heterogeneity of BPD and “the importance of considering individual differences in the motivation to approach versus avoid intimacy in this population” (Bartz et al., 2010).

The novel finding that OXT disinhibited cooperative behaviour for certain BPD individuals further suggests that OXT enhances social cues rather than simply promotes trust and that dysregulation of the OXT system may be symptomatic of BPD. This lead the authors to speculate that

OXT may activate approach behaviours (Kemp & Guastella, 2010) and/or a desire to affiliate (Taylor, 2006) but again, this motivation may remind BPD/anxiously attached participants of previous experiences when affiliation has gone awry and set in motion their chronic concerns about trust and closeness.

(Bartz et al., 2010).


Synthesis/conclusion

Musical improvisation and the neurologic role of neuropeptides may seem to be unrelated fields but for the cognitive scientist, these apparently unrelated areas of human functioning can reveal valuable insights into the functioning of the human mind. The purpose of improvisation in music therapy is to “create an intimate interpersonal relationship between music therapist and client” (Pavlicevic, 2000). This domain of interpersonal relations is of interest to the field of cognitive science and improvisation provides a novel way to investigate this process. The role and/or dysfunction of hormonal systems in psychopathology can also reveal a great depth of information in this field for the cognitive scientist, contributing to both functional and philosophical debates on the workings of the mind. Oxytocin is one such of these neuropeptides and although its function is not clearly understood, it appears to play a central role in interpersonal processes and social functioning. While traditionally thought to promote pro-social behaviour, this view has recently come under question and it is now thought to enhance the salience of social cues rather than strictly promote pro-social behaviour (Harari-Dehan & Bernstein, 2014). One of the primary roles of the cognitive scientist may be to examine the intersection of diverse fields that seldom speak to each other and this synthesis of the above papers aims to do just that.

Possibly the most striking concurrence across the two papers is the heterogeneity of BPD across individuals. Each paper revealed significant within group differences in behaviour which appeared to depend on the type of attachment manifest within any given individual. Anxious and avoidant general attachment styles diverged with the MD_m_B1 - MD_m_B2 variable in Foubert, Collins & De Backer (2017). In the second paper, low avoidance and high avoidance diverged with the level of actual cooperative behaviour. This implication may be of interest to the field of cognitive science (among other disciplines) as the heterogeneity of BPD may have implications for

1. the manner of psychopathological classification of BDP

2. the role of neuropeptides in interpersonal functioning

3. the functionality of interpersonal relations

The heterogeneity of BPD that was noted in both papers presents implications for possible treatment approaches when working with this population (both in music therapy and other therapies) highlighting the possible requirement of different approaches depending on attachment style.

Both papers rationalise the respective divergences (within the BPD group) in different manners. Foubert, Collins and De Backer (2017) suggest that “when the (insecure) attachment system of the patient was activated, difficulties were found in maintaining and improving temporal IPS”. Bartz et al., (2010) rationalise that one (of a number of) explanation(s) may be that “whether OXT promotes or hinders pro-social behaviour depends on the individual and their social repertoire, and/or the social context”. They did also note that “if OXT enhances the salience of social cues… it might be an ideal way to facilitate the learning of new relational schemas and interpersonal skills” which could be of relevance to music therapy (and other) interventions.

Only one previous study (Keeler et al., 2015) has been conducted examining OXT and musical improvisations and while the results were statistically insignificant, the study suggested that improvised singing resulted in an increase in OXT production compared to singing precomposed songs with typical individuals. The finding from paper one that improvisations were able to predict BPD in individuals with an 82% success rate due to a lack of improvement in IPS across the B section may be significant for OXT production. As it has been suggested that OXT production increases the salience of social cues (Shamay-Tsoory et al., 2009), a future candidate for study could be an examination of the relationship between improvisation and OXT production across musical improvisations with a BPD population.

The findings from paper two (that OXT appeared to decrease trust and cooperative behaviour in anxious avoidant BPD individuals) taken alongside the finding from paper one (that suggests improvisation increased IPS in avoidant general attachment individuals) may indicate that improvisation in a music therapy context may be a possible candidate for regulating the OXT system. This suggestion is highly speculative however and more research in this area is needed. A more thorough breakdown of the influence of different attachment styles from paper one could also shed more light on this question. Although Foubert, Collins and De Backer (2017) differentiated between anxious and avoidant individuals reactions, they did not go into the same attachment detail as Bartz et al., (2010) who were more specific in their attachment descriptions. This difference in descriptive power may be due to the measures that were used in each case with the former using the relationship structures questionnaire (Fraley et al., 2011) and the latter using the experience in close relationships scale (Brennan et al., 1998). Another relevant candidate for future study resulting in the synthesis of these papers would be an examination of the effects of intranasal OXT on the IPS of individuals across a musical improvisation with respect to various attachment types.


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