Assessing advanced theory of mind and alexithymia in patients suffering from enduring borderline personality disorder

A meta-analysis of theory of mind and 'mentalization' in borderline personality disorder: a true neuro-social-cognitive or meta-social-cognitive impairment?

BACKGROUND

It is widely accepted that borderline personality disorder (BPD) is associated with significant impairments in mentalization and theory of mind (ToM) which are considered as closely related concepts by many authors particularly in psychoanalytical circles. However, for understanding interpersonal difficulties in personality disorders, it is important to distinguish neuro-social cognitive impairment from the abnormal meta-social-cognitive style of patients.

METHODS

The current systematic review aimed to conduct separate meta-analyses of 'mentalization' [reflective functioning (RF] and different aspects of ToM in BPD. A literature search was conducted to locate relevant articles published between January 1990 to July 2021. Random-effect meta-analyses were conducted in 34 studies involving 1448 individuals with BPD and 2006 healthy controls.

RESULTS

A very large impairment in RF was evident in BPD [d = 1.68, confidence interval (CI) = 1.17-2.19]. In contrast, ToM impairment was modest (d = 0.36, CI = 0.24-0.48). BPD patients underperformed healthy controls in ToM-reasoning (d = 0.44, CI = 0.32-0.56) but not ToM-decoding. Increased HyperToM (d = 0.60, CI = 0.41-0.79) and faux pas recognition (d = 0.62, CI = 0.35-0.90) errors in BPD compared to healthy controls were most robust ToM findings in this meta-analysis.

CONCLUSIONS

BPD is characterized by very severe deficits in RF and modest and selective abnormalities in ToM. Interpersonal problems and difficulties in processing social information in BPD can be best explained by patients' maldaptive meta-social cognitive style and top-down effects of these abnormalities rather than having a primary neuro-social cognitive deficit.

Impaired complex theory of mind and low emotional self-awareness in outpatients with borderline personality disorder compared to healthy controls: A cross-sectional study

Studies on the theory of mind (TOM) and alexithymia in borderline personality disorder (BPD) have yielded inconsistent results. Also, the relationship between TOM abilities and alexithymia facets as two domains of social cognition has not been studied in BPD. This study aimed to fill this gap. Participants were 50 outpatients with BPD and 50 age and gender-matched healthy controls. Assessments performed using Reading the Mind in Eyes Task (RMET), Toronto Alexithymia Scale (TAS-20), Faux Pas Task (FPT), and Digit Span subtest of Wechsler Adult Intelligence Scale. Results showed that BPD patients scored lower on overall FPT (p < .001) and its cognitive (p < .001) and affective TOM (p < .001) subtests but were comparable with healthy controls in emotion recognition ability assessed by RMET (p = .241). The BPD group also scored significantly lower in overall alexithymia (p < .001) and subscales of difficulty identifying feelings (DIF; p < .001) and difficulty describing emotions (DDF; p = .001). However, they performed similarly to the healthy control group in externally oriented thinking (EOT; p = .164). Correlation analysis revealed a significant negative correlation between EOT and RMET in the BPD group (r = -0.33, p < .05). No association, however, was found between FPT and RMET. This study suggests that BPD patients are impaired in the complex TOM abilities and have lower self-awareness of emotions, but their recognition of others' emotions is intact. Also, the results demonstrate that a heightened level of EOT is associated with difficulties in facial emotion recognition in BPD patients.

The relationship between alexithymia and theory of mind: A systematic review

Theory of Mind (ToM), the ability to represent the mental states of oneself and others, is an essential social skill disrupted across many psychiatric conditions. The transdiagnostic nature of ToM impairment means it is plausible that ToM impairment is related to alexithymia (difficulties identifying and describing one's own emotions), as alexithymia is seen across psychiatric conditions. Whilst many studies have examined links between alexithymia and ToM, results are mixed. Therefore, the purpose of this systematic review is to provide a taxonomy of ToM tests and assess their relationship with alexithymia. Tests are grouped according to whether they assess propensity to engage spontaneously in ToM or accuracy of ToM inferences, with tests further subdivided into those that do, and do not, require emotion recognition. A review of 63 suitable studies suggests that alexithymia is often associated with reduced ToM, and inaccurate ToM when tasks require emotion recognition. This latter finding appears due to impaired emotion recognition, rather than ToM impairment per se. Further directions and considerations for future research are discussed.

A systematic review and meta-analysis of 'Systems for Social Processes' in borderline personality and substance use disorders

Deficits in social processing (SP) have been proposed to underpin interpersonal dysfunction in both Borderline Personality Disorder (BPD) and Substance Use Disorders (SUD). This study aimed to explore potential transdiagnostic cognitive and behavioral phenotypes of these disorders utilizing the NIMH Research Domain Criteria 'Systems for Social Processes'. A systematic review and meta-analysis of the published research was conducted on 134 studies identified through our database searches. Four meta-analyses were conducted, which revealed significant overlapping deficits in the ability to identify facial emotions and infer the mental states of others in both BPD and SUD. Further, people with BPD displayed a higher ostracism effect following perceived social exclusion. Systematically reviewed studies also revealed significant dysfunction amongst individuals with BPD and SUD across both self and other SP constructs, which were broadly similar in magnitude. Taken together, these results support the proposition that SP dysfunction may be considered a core transdiagnostic phenotype of BPD and SUD.

Evidence for Altered Neural Processing in Patients With Borderline Personality Disorder

Abstract. Borderline personality disorder (BPD) is characterized by difficulties in emotion regulation, self-identity disturbances, self-injurious behavior, and reduced inhibitory control. Event-related potential (ERP) studies have sought to reveal the neural correlates of cognitive distortions and behavioral alterations in BPD. The article presents an overview of the existing ERP literature pertaining to BPD and discusses whether any one of the electrophysiological findings could serve as a reliable and specific marker for BPD. In short, ERP studies investigating P300 tentatively suggest impaired inhibitory control. Moreover, reduced error- and feedback-related processing and impaired response inhibition seem to be associated with impulsivity and risk-taking behavior in BPD patients. However, these findings are not specific for BPD. Regarding emotional and self-referential information processing, individuals with BPD display heightened vigilance toward social threat impacting their cognitive performance in various social-cognitive tasks demonstrating alterations of early negative and late positive potentials. These multifaceted electrophysiological alterations may be attributed to dysfunctional activity and connectivity of frontal brain regions and the limbic system.

Empathy, Alexithymia, and Theory of Mind in Borderline Personality Disorder

The purpose of this research was to determine the differences in empathy, alexithymia features, and theory of mind between healthy controls and patients with borderline personality disorder (BPD). Thirty-five patients with BPD and 35 healthy controls were included in the study. To measure the clinical variables, the Empathy Quotient (EQ), Reading the Mind in the Eyes Test (RMET), Toronto Alexithymia Scale (TAS-20), Barratt Impulsivity Scale-11 (BIS-11), and Beck Depression Inventory (BDI) were applied. We found that the BPD group had significantly worse total RMET and neutral RMET scores than the control group. There were no differences in the EQ scores between the BPD and control groups. The patients with BPD were more alexithymic than the controls, and alexithymia and depression scores predicted BPD status. Patients with BPD who have difficulty identifying their own emotions tend to display deficits in perceptions of facial emotions, which, in turn, may lead to misperceptions of social signals and thus contribute to excessive emotional intensity and tension in social situations. The study results reveal that alexithymia and depression are important variables in predicting BPD traits.

Examining the Relationship Between Executive Functions and Mentalizing Abilities of Patients With Borderline Personality Disorder

Patients with borderline personality disorder (BPD) experience interpersonal dysfunctions; therefore, it is important to understand their social functioning and the confounding factors. We aimed to investigate the mentalizing abilities and executive functioning (EF) of BPD patients and healthy subjects and to determine the relative importance of BPD diagnosis and EF in predicting mentalizing abilities while controlling for general IQ and comorbid symptom severity. Self-oriented mentalizing (operationalized as emotional self-awareness/alexithymia), other-oriented mentalizing [defined as theory of mind (ToM)], and several EF domains were examined in 18 patients with BPD and 18 healthy individuals. Decoding and reasoning subprocesses of ToM were assessed by standard tasks (Reading the Mind in the Eyes Test and Faux Pas Test, respectively). Relative to controls, BPD patients exhibited significant impairments in emotional self-awareness and ToM reasoning; however, their ToM decoding did not differ. Multivariate regression analyses revealed that comorbid psychiatric symptoms were negative predictors of alexithymia and ToM decoding. Remarkably, the diagnosis of BPD was a positive predictor of ToM decoding but negatively influenced reasoning. Moreover, EF had no impact on alexithymia, while better IQ, and EF predicted superior ToM reasoning. Despite the small sample size, our results provide evidence that there is a dissociation between mental state decoding and reasoning in BPD. Comorbid psychiatric symptoms could be considered as significant negative confounds of self-awareness and ToM decoding in BPD patients. Conversely, the impairment of ToM reasoning was closely related to the diagnosis of BPD itself but not to the severity of the psychopathology.

The role of alexithymia in social cognition: Evidence from a non-clinical population

BACKGROUND

Alexithymia is a personality construct characterised by difficulty in identifying and describing one's emotions. We investigated whether people with alexithymia, who struggle with emotion-processing abilities, have diminished emotion-related social cognitive competencies, where social cognition encompasses the set of abilities that allows one to navigate one's social environment.

METHODS

We assessed alexithymia and four components of social cognition: recognition of others' emotions, representation of others' affective and cognitive mental states, empathy, and regulation of one's own feelings. We investigated whether alexithymia could significantly predict each of these components, beyond the effect of other individual difference variables (i.e., anxiety/depressive symptoms), which have been previously associated with both social cognition and alexithymia. Two hundred six participants were recruited. Multiple hierarchical regression analyses were performed to assess the possible relationships between alexithymia and social cognition skills.

RESULTS

Alexithymia significantly predicted emotion recognition, empathy, and emotional regulation, even after controlling for the effect of potentially competing factors (i.e., anxiety/depressive symptoms). Alexithymia did not predict representation of others' affective and cognitive mental states.

LIMITATIONS

The present study adopted a cross-sectional design, which does not permit us to draw firm conclusions about the causality of the emergent relationships.

CONCLUSIONS

These data provide support for the argument that recognising others' emotions and feelings relies on the ability to identify correctly one's own feelings. Our results also indicate the importance of taking into consideration individual differences in levels of alexithymia when investigating social cognition in non-clinical populations, as alexithymia appears to be clearly related to social cognitive functioning.

Dysfunction of Empathy and Related Processes in Borderline Personality Disorder: A Systematic Review

After participating in this activity, learners should be better able to:• Assess differences between adult patients with the diagnosis of borderline personality disorder (BPD) and healthy control subjects in terms of empathy and related processes• Evaluate the effects of empathy or related processes as factors contributing to abnormal social functioning in BPD ABSTRACT: We reviewed 45 original research studies, published between 2000 and 2019, to assess differences between adult patients with the diagnosis of borderline personality disorder (BPD) and healthy control subjects in terms of empathy and related processes (i.e., theory of mind, mentalizing, social cognition, and emotional intelligence). Thirty-six studies reported deficits of empathy or related processes in patients with BPD. Enhanced emotional empathy in BPD was also reported in eight studies, all of which revealed that patients had increased scores of personal distress on the Interpersonal Reactivity Index self-report questionnaire. Six studies did not find significant differences between patients with BPD and healthy control subjects in terms of empathy or related processes. No study reported enhanced cognitive empathy, social cognition, or emotional intelligence in patients with BPD. We postulate that deficits of empathy or related processes contribute to preempting the formation of stable interpersonal relationships, whereas enhanced emotional empathy might lead to personal (and interpersonal) distress, further contributing to abnormal social functioning in BPD.

Disguised Emotion in Alexithymia: Subjective Difficulties in Emotion Processing and Increased Empathic Distress

Despite decades of speculation, many causal aspects that contribute to the heterogeneity of alexithymia still must be clarified. This study examined the extent of the alexithymia phenotype and its contribution to social function in the general population. In total, 200 participants (females = 111) completed the Toronto Alexithymia Scale-20 (TAS-20), multiple self-reporting questionnaires measuring emotion intelligence, empathy, hostility and impulsivity, and the Reading the Mind in the Eyes Test (RMET). In the multivariate analysis, highly alexithymic individuals appeared to report subjective deficits in emotion recognition and regulation as well as increased impulsivity; however, their empathy skills were intact, and even the proneness to experiencing empathic distress with others' suffering was increased among alexithymic individuals. We also compared the clinical and behavioral manifestations of highly alexithymic male and female subjects to those of each gender control group. As a result, in contrast to their subjective self-reports of emotion processing impairment, the RMET performance appeared to be preserved in alexithymic females; however, highly alexithymic males showed actual deficits in the emotion identification task. Future research needs to further refine the constructs of alexithymia to incorporate the phenotypic changes in affected individuals in relation to measuring instruments, the extent of empathic distress, and gender.

Assessing self-reported empathy and altruism in patients suffering from enduring borderline personality disorder

Self-report studies on empathy in adults with borderline personality disorder (BPD) have based upon the Interpersonal Reactivity Index (IRI) and generally identified deficits in perspective taking abilities in this group, but indicated less coherent results regarding empathic concern. These two constructs are considered subcomponents of cognitive (CE) and affective empathy (AE), respectively. However, the IRI does not enable for valid investigation of overall levels of these empathy types. Surprisingly, although some findings from the general population suggest that empathy types may be positively related to altruism, neither this link nor general altruism have been examined in BPD. Additionally, these constructs have not been sufficiently studied in this group in the context of alexithymia or potential clinical confounders. Hence, women with BPD (N = 30) and healthy women (N = 38) completed, i.a., the Questionnaire of Cognitive and Affective Empathy, Self-Report Altruism Scale, TAS-20, STAI, and CESD-R. Patients with BPD reported significantly decreased overall CE (including worse online simulation abilities - conceptually similar to perspective taking from the IRI), but a similar level of overall AE. They also demonstrated lower altruism. Taken together, these results suggest that BPD patients have difficulties with imagining what emotions others are feeling and with altruistic responding to their needs.

Cognitive impairment in substance use disorders

Cognitive impairments in substance use disorders have been extensively researched, especially since the advent of cognitive and computational neuroscience and neuroimaging methods in the last 20 years. Conceptually, altered cognitive function can be viewed as a hallmark feature of substance use disorders, with documented alterations in the well-known "executive" domains of attention, inhibition/regulation, working memory, and decision-making. Poor cognitive (sometimes referred to as "top-down") regulation of downstream motivational processes-whether appetitive (reward, incentive salience) or aversive (stress, negative affect)-is recognized as a fundamental impairment in addiction and a potentially important target for intervention. As addressed in this special issue, cognitive impairment is a transdiagnostic domain; thus, advances in the characterization and treatment of cognitive dysfunction in substance use disorders could have benefit across multiple psychiatric disorders. Toward this general goal, we summarize current findings in the abovementioned cognitive domains of substance use disorders, while suggesting a potentially useful expansion to include processes that both precede (precognition) and supersede (social cognition) what is usually thought of as strictly cognition. These additional two areas have received relatively less attention but phenomenologically and otherwise are important features of substance use disorders. The review concludes with suggestions for research and potential therapeutic targeting of both the familiar and this more comprehensive version of cognitive domains related to substance use disorders.

Mindreading abilities and borderline personality disorder: A comprehensive assessment using the Theory of Mind Assessment Scale

Numerous studies have examined mindreading in borderline personality disorder (BPD). However, the empirical data obtained to date have not facilitated the development of a clear clinical profile of mindreading impairment in BPD due to a lack of consistency or incongruence across studies. One possible explanation for these inconsistencies and divergences in the current literature may lie in the multidimensional character of the mindreading construct; moreover, the heterogeneity of the experimental measures used to assess individuals with BPD mindreading skills may also need to be taken into account. The aim of the present study is to investigate mindreading skills and impairments in patients with BPD through direct comparison of a wide range of mindreading dimensions using a comprehensive semistructured interview, the Theory of Mind Assessment Scale (Th.o.m.a.s.) (Bosco et al., 2009). Our results show that the performance of patients with BPD differs from that of healthy controls only in certain specific dimensions of mindreading. The difficulties encountered by the patients with BPD typically emerge when mindreading tasks require them to disentangle their own subjective mindreading from that of another person, in other words, when they were required to assume an allocentric perspective.