Eye-Tracking and Borderline Personality Disorder: A Systematic Review

Area of Science:

• Neuroscience
• Psychiatry
• Psychology

Background:

• Borderline personality disorder (BPD) is a severe mental disorder characterized by emotion dysregulation, impulsivity, and interpersonal hypersensitivity.
• Prevalence of BPD ranges from 0.5% to 6.4%.
• Eye tracking and pupillometry offer objective insights into social attention and inhibitory control, yet a systematic review of their use in BPD was lacking.

Purpose of the Study:

• To synthesize empirical evidence on visuo-attentional and pupillary alterations in individuals with BPD.
• To systematically review the literature on eye-tracking and pupillometry in BPD.

Main Methods:

• A systematic literature search was conducted across Web of Science, Scopus, and PubMed up to March 13, 2026, adhering to PRISMA 2020 guidelines.
• Search terms combined "borderline personality disorder" with eye-tracking constructs.
• Seventeen studies were included, with risk of bias assessed using appropriate frameworks (RoB 2, Newcastle-Ottawa Scale logic, ROBINS-I).

Main Results:

• Patients with BPD exhibited early vigilance to facial eye regions, followed by reduced engagement with positive stimuli.
• Elevated self-reported impulsivity was noted, with largely preserved laboratory inhibition, except for preparatory control deficits, especially in comorbid ADHD or negative affect.
• Autonomic dysregulation was indicated by lower heart-rate variability and larger baseline pupil size; pupillary reactivity predicted symptom change in one longitudinal study.
• Intranasal oxytocin was found to reduce amygdala-driven vigilance.

Conclusions:

• Eye-tracking and pupillometric measures effectively capture significant aspects of the BPD clinical presentation.
• A vigilance-avoidance pattern, characterized by initial vigilance and subsequent reduced engagement, is suggested.
• Findings primarily apply to adult women due to sample limitations; future research needs standardized protocols, transdiagnostic comparisons, and diverse populations.