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

Borderline personality disorder is an innate empathy anomaly: a scoping and narrative review

BACKGROUND

Studying empathy in borderline personality disorder (BPD) is essential because difficulties with interpersonal functioning are integral.

OBJECTIVES

This scoping and narrative review explores the aetiological theory that BPD is an innate anomaly of cognitive empathy, with a normal or heightened emotional empathy.

ELIGIBILITY CRITERIA AND SOURCES OF EVIDENCE

Ovid MEDLINE(R) ALL was searched using the terms empathy; theory of mind; mentalisation or mentalising; borderline empathy; emotion recognition and BPD. For inclusion in the scoping review, articles needed to empirically assess an empathic skill in people with BPD, or self-reported empathy in a BPD group compared to controls, or empathic skill as a 'borderline feature' in a nonclinical sample.

CHARTING METHOD

The results of empirical studies were categorised as per their methodological approach, with results in the BPD group reported as comparable, enhanced or reduced compared to controls.

RESULTS

320 articles were returned, with 38 eligible. The majority affirmed that people with BPD have an anomalous empathetic ability, especially a deficient cognitive empathy. Furthermore, this is trait, evident early in development, correlates with syndrome severity, and is mediated by atypical neural networks.

CONCLUSIONS

This substantiates the theory that BPD is, at least in major part, an innate empathy anomaly.

Alexithymia and Personality Pathology

Alexithymia is an important transdiagnostic risk factor for many psychopathologies. To explore its relevance for personality disorders, we examined the association between alexithymia and maladaptive personality traits, as conceptualized within the DSM-5-TR Alternative Model for Personality Disorders (i.e., negative affect, detachment, antagonism, disinhibition, psychoticism). Participants (N = 651) completed a battery of psychometric questionnaires. Regressions revealed that alexithymia facets accounted for a significant 15% of the variance in negative affect, 22% in detachment, 11% in antagonism, 18% in disinhibition, and 25% in psychoticism. Latent profile analysis showed that profiles with more severe personality pathology were generally characterized by more severe levels of alexithymia. Overall, our data highlight that alexithymia is important in understanding personality dysfunction. All facets of alexithymia, across both positive and negative emotions, are linked to each maladaptive personality trait. The assessment and targeting of alexithymia may therefore be of high relevance for the treatment of personality pathology.

The implication of alexithymia in personality disorders: a systematic review

BACKGROUND

Alexithymia, characterized by difficulty identifying and expressing emotions, is often associated with various psychiatric disorders, including personality disorders (PDs). This study aimed to explore the relationship between alexithymia and PD, focusing on their common origins and implications for treatment.

METHODS

A systematic review was conducted following PRISMA guidelines using databases such as MEDLINE (PubMed), Scopus, and Web of Science. The inclusion criteria were studies assessing adults with DSM-5-diagnosed personality disorders using validated alexithymia scales. The Newcastle‒Ottawa Scale was used to assess the quality of the included studies.

RESULTS

From an initial yield of 2434 citations, 20 peer-reviewed articles met the inclusion criteria. The findings indicate a significant association between alexithymia and personality disorders, particularly within Clusters B and C. Patients with these disorders exhibited higher levels of alexithymia, which correlated with increased emotional dysregulation and interpersonal difficulties. The review also highlighted the comorbidity burden of conditions such as psychosomatic disorders, eating disorders, depression, anxiety, suicidal behavior, and substance use disorders.

CONCLUSIONS

These findings underscore the need for integrating alexithymia-focused assessments into clinical practice to enhance therapeutic approaches, allowing for more personalized and effective interventions. Addressing the emotional processing challenges in patients with personality disorders could significantly improve patient outcomes. Future research should prioritize establishing clinical guidelines and conducting longitudinal studies to explore the relationship between alexithymia and specific personality disorder subtypes, ensuring the practical translation of these findings into clinical practice.

The Role of Hopelessness in Patients With Borderline Personality Disorder

BACKGROUND

The goal of this study was to evaluate specific characteristics associated with hopelessness, potentially correlated with coping strategies, sensory profile, and alexithymia in patients with borderline personality disorder (BPD).

MATERIALS AND METHODS

Two hundred twenty-four (N=224) inpatients completed a clinical interview with administration of the Beck Hopelessness Scale (BHS), the Adolescent/Adult Sensory Profile (AASP), the Coping Orientation to Problems Experienced Inventory (COPE), and the Toronto Alexithymia Scale (TAS).

RESULTS

Hopelessness was significantly associated with female gender, more hospitalizations, current suicidal ideation, number of suicide attempts, current and lifetime medication abuse, and alcohol misuse. Furthermore, patients with BHS ≥ 9 had higher scores in low registration, sensory sensitivity and sensation avoiding in AASP, higher rate of alexithymia, and the use of maladaptive coping strategies.

CONCLUSIONS

Hopelessness in BPD was associated with higher severity of illness, alternative process sensory input from the environment, reduced ability to cope with stressful events, and alexithymia. Therefore, a routine assessment of hopelessness in patients with BPD could lead to better and more specific therapeutic strategies.

Assessing social cognition in patients with schizophrenia and healthy controls using the reading the mind in the eyes test (RMET): a systematic review and meta-regression

The reading the mind in the eyes test (RMET) - which assesses the theory of mind component of social cognition - is often used to compare social cognition between patients with schizophrenia and healthy controls. There is, however, no systematic review integrating the results of these studies. We identified 198 studies published before July 2020 that administered RMET to patients with schizophrenia or healthy controls from three English-language and two Chinese-language databases. These studies included 41 separate samples of patients with schizophrenia (total n = 1836) and 197 separate samples of healthy controls (total n = 23 675). The pooled RMET score was 19.76 (95% CI 18.91-20.60) in patients and 25.53 (95% CI 25.19-25.87) in controls (z = 12.41, p < 0.001). After excluding small-sample outlier studies, this difference in RMET performance was greater in studies using non-English v. English versions of RMET (Chi [Q] = 8.54, p < 0.001). Meta-regression analyses found a negative association of age with RMET score and a positive association of years of schooling with RMET score in both patients and controls. A secondary meta-analysis using a spline construction of 180 healthy control samples identified a non-monotonic relationship between age and RMET score - RMET scores increased with age before 31 and decreased with age after 31. These results indicate that patients with schizophrenia have substantial deficits in theory of mind compared with healthy controls, supporting the construct validity of RMET as a measure of social cognition. The different results for English versus non-English versions of RMET and the non-monotonic relationship between age and RMET score highlight the importance of the language of administration of RMET and the possibility that the relationship of aging with theory of mind is different from the relationship of aging with other types of cognitive functioning.

[Alexithymia and self-harm in people with borderline personality disorder]

OBJECTIVE

To estimate the prevalence of alexithymia and self-harm in patients with borderline personality disorder (BPD). To assess the role of alexithymia in the emergence of self-harm in patients with BPD.

MATERIAL AND METHODS

We studied 104 patients (85 women, 19 men aged 21 to 25 years (64.4%)), including 54 patients with and 50 patients without BPD. Most of them had incomplete higher education (55%). We used the Russian version of the 20-item Toronto Alexithymia Scale (TAS-20) to reveal alexithymia and SCID-II to diagnose BPD. The presence of self-harm behavior was confirmed by the subjects' anamnesis data.

RESULTS

The prevalence of alexithymia in patients with BPD was 83.3%, in the control group it was 52% (p=0.001). The prevalence of self-aggression was 70.3% (n=38) in patients with BPD, and 12% (n=6) in people without BPD. Self-harm among persons with alexithymia was noted in 62.5% (n=45). During the analysis, a connection between auto-aggression and alexithymia was found at the level of a statistical trend (p=0.051).

CONCLUSION

Alexithymia and self-harm are more common in patients with BPD than in healthy people. This type of emotional dysregulation mediates self-harm in patients with BPD.

Four attachment-based categories of emotion regulation in adolescent psychic troubles

Introduction

Emotion regulation is altered in many psychiatric disorders in adolescence, but the understanding of mechanisms that underlie this alteration is still poor.

Methods

The PERCEPT study explores alexithymia, empathy, facial emotion recognition (FER) and defence mechanisms in a sample of adolescents in psychiatric care (n = 61, 74% of girls, mean age = 15.03 y.o.), in relation with participants' attachment styles.

Results

Results revealed correlations between attachment dimensions and all of the emotion regulation variables, suggesting that attachment modalities have functional links with emotional regulation at its different levels: FER accuracy was inversely correlated with avoidant attachment, while affective empathy, difficulty in identifying feelings (alexithymia) and immature as well as neurotic defence mechanisms were positively correlated with anxious attachment. Moreover, attachment categories delineated distinct emotional perception profiles. In particular, preoccupied attachment included adolescents with the highest levels of facial emotion perception (sensitivity and accuracy) and of affective empathy, whereas detached attachment included adolescents with the lowest levels of these variables. Neurotic defence mechanisms and difficulty to identify feelings were correlated with preoccupied attachment; immature defence mechanisms and difficulty to describe feelings to others characterized fearful attachment.

Discussion

These results suggest that attachment categories underlie emotion regulation processes in psychiatric disorders in adolescence. Theoretical and clinical implications are discussed.

The Role of Gender in Patients with Borderline Personality Disorder: Differences Related to Hopelessness, Alexithymia, Coping Strategies, and Sensory Profile

Background and Objectives: Gender differences are poorly investigated in patients with borderline personality disorder (BPD), although they could be useful in determining the most appropriate pharmacological and non-pharmacological treatment. The aim of the present study was to compare sociodemographic and clinical characteristics and the emotional and behavioral dimensions (such as coping, alexithymia, and sensory profile) between males and females with BPD. Material and Methods: Two hundred seven participants were recruited. Sociodemographic and clinical variables were collected through a self-administered questionnaire. The Adolescent/Adult Sensory Profile (AASP), Beck Hopelessness Scale (BHS), Coping Orientation to Problems Experienced (COPE), and Toronto Alexithymia Scale (TAS-20) were administered. Results: Male patients with BPD showed more involuntary hospitalizations and greater use of alcohol and illicit substances compared to females. Conversely, females with BPD reported more frequent medication abuse than males. Furthermore, females had high levels of alexithymia and hopelessness. Regarding coping strategies, females with BPD reported higher levels of "restraint coping" and "use of instrumental social support" at COPE. Finally, females with BPD had higher scores in the Sensory Sensitivity and Sensation Avoiding categories at the AASP. Conclusions: Our study highlights gender differences in substance use, emotion expression, future vision, sensory perception, and coping strategies in patients with BPD. Further gender studies may clarify these differences and guide the development of specific and differential treatments in males and females with BPD.

Affective cognition in eating disorders: a systematic review and meta-analysis of the performance on the "Reading the Mind in the Eyes" Test

BACKGROUND

The Reading the Mind in the Eyes Test (RMET) is listed in the National Institute of Mental Health's Research Domain Criteria as a tool apt to measure the understanding of others' mental states. People diagnosed with anorexia nervosa (AN) showed poorer performances on the RMET than healthy controls. Less data are available concerning other eating disorders.

METHODS

Systematic review of four major databases from inception to July 15, 2021 following the PRISMA guidelines. Meta-analysis of cross-sectional observational studies comparing the scores of the RMET between patients with eating disorders and age- and-gender matched control groups.

RESULTS

Out of 21 studies, we retrieved 29 independent samples of patients diagnosed with an eating disorder. Patients with active AN (n = 580) showed worse performances on the RMET than controls (n = 1019). Year of publication accounted for 61% of the (substantial: I2 = 81%) heterogeneity in the meta-analysis. Earlier studies were more likely to find worse performances on the RMET of patients with active AN than later studies. Patients with bulimia nervosa (n = 185) performed poorly as compared to controls (n = 249), but the results were not statistically significant on the random-effect model. Obese patients with binge-eating disorder (n = 54) did not differ on the RMET from obese controls (n = 52). Patients with eating disorder not otherwise specified (n = 57) showed minimal differences compared to controls (n = 96). Study quality was good in six studies only.

CONCLUSIONS

Patients with eating disorders do not suffer from an impaired understanding of others' mental states, except for a still-to-be-identified subgroup of patients with active AN.

LEVEL OF EVIDENCE

I, systematic review and meta-analysis.

Altered hormonal patterns in borderline personality disorder mother-child interactions

BACKGROUND

Oxytocin, cortisol, and testosterone are involved in the processing of reward and stress and greatly influence mother-child interactions. Altered hormonal systems have been associated with borderline personality disorder (BPD), a disorder characterized by interpersonal deficits. Mothers with BPD tend to perceive interactions with the child as less rewarding and more stressful and interactions are often less reciprocal and have more negative states (i.e. constricted, tense, uncoordinated behaviors). Their children are at elevated risk for psychopathologies. Here, we studied underlying hormonal mechanisms of disrupted mother-child interaction in BPD.

METHODS

Twenty-five mothers with BPD and 29 healthy mothers with their 18- to 36-month-old toddlers participated in a free-play mother-child interaction, which was evaluated with the Coding Interactive Behavior (CIB) Manual. Maternal blood samples were analyzed at baseline for oxytocin, cortisol, and testosterone, and after interaction for oxytocin and cortisol.

RESULTS

Oxytocin decreased and cortisol remained unchanged in mothers with BPD while healthy mothers showed stable oxytocin and decreased cortisol after interaction. Testosterone basal levels were significantly higher in mothers with BPD. Cortisol reactivity and testosterone levels mediated the association between maternal BPD and dyadic negative states during interaction.

CONCLUSIONS

These findings suggest that alterations in oxytocin, cortisol, and testosterone contribute to disruptions in mother-child interaction in BPD. Interacting with their child might not result in reward and relief of stress in mothers with BPD in the same way as in healthy mothers. Further research is needed to understand more about dyadic bio-behavioral processes in order to provide targeted parenting support. This could break the cycle of transgenerational transmission and improve maternal and child well-being.

Associations between alexithymia, parental rearing styles, and frequency of drug use in male methamphetamine dependence patients

BACKGROUND

Alexithymia, which is characterized by difficulty identifying and describing feelings, is a stable personality trait and it has been associated with early life experiences. Methamphetamine dependence patients with high level of alexithymia may be particularly vulnerable to engaging in more frequent methamphetamine use. Therefore, we aimed to evaluate whether alexithymia was associated with frequency of methamphetamine use. Additionally, the current study sought to examine early-life factors associated with the development of alexithymia, i.e., parental rearing styles.

METHOD

Participants were 108 non-injecting methamphetamine dependent patients from a male compulsory detoxification center. The level of alexithymia was assessed by Toronto Alexithymia Scale-20(TAS-20). In addition, we applied Egna Minneu av. Bardndosnauppforstran (EMBU) to assess the parental rearing styles, including the dimensions of warmth, rejection, punishment/strictness, overinvolvement, overprotection, and favoring.

RESULTS

The total score of TAS-20 was positively correlated with frequency of methamphetamine use (r = 0.26, p < 0.01). Specifically, except for externally oriented thinking, difficulty identifying feelings (r = 0.23, p < 0.05) and difficulty describing feelings (r = 0.25, p < 0.05) were positively correlated with frequency of methamphetamine use. Multiple linear regression showed that more maternal rejection (B = 0.59, p = 0.002), or less maternal warmth (B = -0.22, p = 0.004) was associated with higher levels of alexithymia. Ordinal logistic regression showed that for every 1 score increase in the total score of TAS-20, there was a 1.06 times risk of a one level increase in the level of methamphetamine use frequency (OR = 1.06, p = 0.01).

CONCLUSIONS

These results have major implications for understanding the role of alexithymia in craving and addiction, while providing a further and explicit entry point for addiction treatment. Moreover, more attention should be focused on parenting in relation to early experiences.

Theory of mind performance in depression: A meta-analysis

BACKGROUND

Theory of mind (ToM) is a social-cognitive skill that involves the ability to understand the thoughts and feelings of others. Evidence is mixed regarding the extent of ToM ability in individuals with depression.

METHODS

We conducted a meta-analysis of 43 studies to investigate the strength of the association between ToM and depression.

RESULTS

Results indicated significant, small- to moderate impairment in ToM with a medium overall effect size (g = -0.398) in individuals with depression. Moderator analyses compared effect sizes across groups for the following variables: ToM content, process, and sample type. Additionally, meta-regression analyses tested age and gender as continuous moderators.

LIMITATIONS

The cross-sectional nature of included studies limits this meta-analysis from clarifying temporal or bidirectional relations.

CONCLUSIONS

We discuss findings in the context of the extant developmental, cognitive, social, and clinical literatures. We also suggest several possible explanations for these findings and offer implications for intervention.

The Borderline Bias in Explicit Emotion Interpretation

Atypical emotion interpretation has been widely reported in individuals with borderline personality disorder (iBPD); however, empirical studies reported mixed results so far. We suggest that discrepancies in observations of emotion interpretation by iBPD can be explained by biases related to their fear of rejection and abandonment, i.e., the three moral emotions of anger, disgust, and contempt. In this study, we hypothesized that iBPD would show a higher tendency to correctly interpret these three displays of social rejection and attribute more negative valence. A total of 28 inpatient iBPDs and 28 healthy controls were asked to judge static and dynamic facial expressions in terms of emotions, valence, and self-reported arousal evoked by the observed faces. Our results partially confirmed our expectations. The iBPD correctly interpreted the three unambiguous moral emotions. Contempt, a complex emotion with a difficulty in recognizing facial expressions, was recognized better by iBPD than by healthy controls. All negative emotions were judged more negatively by iBPD than by controls, but no difference was observed in the neutral or positive emotion. Alexithymia and anxiety trait and state levels were controlled in all analyses.

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.