Theory of mind in women with borderline personality disorder or schizophrenia: differences in overall ability and error patterns

Mental health disorders, functioning and health-related quality of life among extensively hospitalized patients due to severe self-harm - results from the Extreme Challenges project

Background

Severe self-harm leading to extensive hospitalization generates extreme challenges for patients, families, and health services. Controversies regarding diagnoses and health care often follow. Most evidence-based treatments targeting self-harm are designed for borderline personality disorder (BPD). However, current knowledge about mental health status among individuals with severe self-harm is limited.

Objectives

To investigate psychopathology among patients extensively hospitalized due to severe or frequent self-harming behaviors.

Method

A cross sectional study (period 2019-2021) targeting psychiatric inpatients (>18 years) with frequent (>5) or long (>4 weeks) admissions last year due to self-harm. The target sample (N = 42, from 12 hospitals across all Norwegian health regions) was compared to individuals admitted to outpatient personality disorder (PD) treatment within specialist mental health services in the same period (N = 389). Clinicians performed interviews on self-harm and psychopathology, supplemented by self-report.

Results

The target sample were young adults, mainly female, with considerable hospitalization and self-harming behaviors, both significantly more extensive than the comparison group. The majority in both groups reported self-harm onset <18 years. The target sample reported increasing severity of self-harm acts and suicidal intention over time. Both samples had high levels of childhood trauma, impaired personality functioning, and a majority fulfilled criteria for PD. In the target sample, comorbid depression, PTSD, anxiety disorders, and substance use occurred more frequently and in 50%, psychosis/dissociative disorder/autism spectrum disorder/ADHD was reported (outpatient comparison sample: 9%). 35% in the target sample screened over cut-off for possible intellectual disability. The target sample reported poor psychosocial functioning and health-related quality of life - greater impairment than the outpatient comparison sample.

Conclusion

The study reveals that severe self-harm inpatients have complex psychopathology and highlights the importance of individualized and thorough assessment among patients with severe and/or repetitive self-harm.

Contrasting social knowledge and theory of mind patterns in adults with personality disorders, schizophrenia spectrum disorders, and healthy controls

INTRODUCTION

Personality disorders (PD) and schizophrenia spectrum disorders (SSD) are distinct conditions displaying common symptoms, like impairments in social cognition, that make them hard to distinguish, especially in severe cases. To date, few studies have compared theory of mind skills in these two disorders, and none have compared social knowledge skills. This study aims to compare the social cognitive abilities of patients with these conditions.

METHOD

Non-parametric analyses of covariance were used to compare severe PD patients (n = 37), SSD patients (n = 44), and healthy controls (HC; n = 49) on the Social Knowledge Test and two measures of theory of mind: the Reading the Mind in the Eyes Test and the Combined Stories Test, which incorporates items from various widely used tests.

RESULTS

While no significant group differences were found on the Social Knowledge Test, SSD patients performed lower than the HC group on both theory of mind tests. PD patients only had lower performance than the HC group on specific items from the Combined Stories Test.

CONCLUSIONS

PD and SSD patients demonstrated distinctive patterns of social cognitive impairments, with items of greater complexity or with an affective orientation being the most discriminant for PD.

Diverging effects of mentalization based treatment for patients with borderline personality disorder and schizophrenia: an explorative comparison

Introduction

There is robust evidence that both patients with schizophrenia (SCZ) and borderline personality disorder (BPD) display mentalizing difficulties. Less is known however about differences in the way mentalization based treatment (MBT) impacts mentalizing capacity in SCZ and BPD patients. This study compares the impact of MBT on mentalizing capacity in individuals with SCZ and BPD.

Method

The thematic apperception test was used to measure mentalizing capacity. It was administered at the beginning and end of treatment to 26 patients with SCZ and 28 patients with BPD who enrolled in an 18-month long MBT program. For comparison a sample of 28 SCZ patients who did not receive MBT was also included. Using the social cognition and object-relations system, these narratives were analyzed and scored. Missing data was imputed and analyzed using intention-to-treat ANCOVAs with post-treatment measures of mentalizing capacity as dependent variables, group type as independent variable and baseline mentalizing capacities as covariates.

Results

Results showed that patients with BPD showed significantly more improvement on several measures of mentalizing, including complexity of representation (ηp2 = 0.50, ppooled < 0.001), understanding of social causality (ηp2 = 0.41, ppooled < 0.001) and emotional investment in relationships (ηp2 = 0.41, ppooled < 0.001) compared to patients with SCZ who received MBT. No differences were found regarding affect-tone of relationships (ηp2 = 0.04, ppooled = 0.36). SCZ patients who received MBT showed greater performance on understanding of social causality (ηp2 = 0.12, ppooled = 0.01) compared to SCZ patients who did not receive MBT, but no differences were observed on complexity of representations, capacity for emotional investment or affect-tone of relationships.

Discussion

Patients with BPD performed better after receiving MBT on three dimensions of mentalizing capacity than SCZ patients who received MBT. Remarkably, SCZ patients who received MBT performed better on one dimension of mentalizing capacity compared to SCZ patients who did not receive MBT. Whereas MBT for BPD clearly involves improvement on most aspects of mentalizing, MBT for SCZ seems to thwart a further decline of other-oriented, cognitive mentalizing. Treatment goals should be adapted toward these disorder-specific characteristics.

Psychopathology and Theory of Mind in patients with personality disorders

OBJECTIVE

People with mental disorders frequently suffer from deficits in the ability to infer other's mental states (Theory of Mind; ToM). Individuals with borderline personality disorder (BPD) show ToM deficits characterized by exceeding ToM (over-attributions of mental states). The present study analyzed associations between ToM, BPD severity, and depression severity in patients with BPD and other personality disorders.

METHOD

We analyzed ToM abilities in 128 patients with BPD and 82 patients with 'mixed and other personality disorders' (MOPD). MOPD are diagnosed if symptoms of multiple personality disorders are present without any set of symptoms being dominant enough to allow a specific diagnosis. We used the movies for the assessment of social cognition (MASC) to measure ToM abilities, the Patient Health Questionnaire (PHQ-9) to assess severity of depression and the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) to assess the severity of BPD symptoms.

RESULTS

Both symptoms of BPD and depression were associated with exceeding ToM in separate regressions. Using a stepwise regression, only the association of depression severity with exceeding ToM was reliable. Patients with BPD and MOPD did not differ in exceeding ToM. Age was most reliably associated with ToM.

CONCLUSION

The results imply that exceeding ToM is associated with general psychopathology instead of BPD-symptoms in specific. Patients with MOPD show deficits similar to BPD patients.

Face pareidolia in male schizophrenia

Faces are valuable signals for efficient social interaction. Yet, social cognition including the sensitivity to a coarse face scheme may be deviant in schizophrenia (SZ). Tuning to faces in non-face images such as shadows, grilled toasts, or ink blots is termed face pareidolia. This phenomenon is poorly investigated in SZ. Here face tuning was assessed in 44 male participants with SZ and person-by-person matched controls by using recently created Face-n-Thing images (photographs of non-face objects to a varying degree resembling a face). The advantage of these images is that single components do not automatically trigger face processing. Participants were administered a set of images with upright and inverted (180° in the image plane) orientation. In a two-alternative forced-choice paradigm, they had to indicate whether an image resembled a face. The findings showed that: (i) With upright orientation, SZ patients exhibited deficits in face tuning: they provided much fewer face responses than controls. (ii) Inversion generally hindered face pareidolia. However, while in neurotypical males, inversion led to a drastic drop in face impression, in SZ, the impact of orientation was reduced. (iii) Finally, in accord with the signal detection theory analysis, the sensitivity index (d-prime) was lower in SZ, whereas no difference occurred in decision criterion. The outcome suggests altered face pareidolia in SZ is caused by lower face sensitivity rather than by alterations in cognitive bias. Comparison of these findings with earlier evidence confirms that tuning to social signals is lower in SZ, and warrants tailored brain imaging research.

Irony detection in patients with borderline personality disorder: an experimental study examining schizotypal traits, response biases and empathy

BACKGROUND

In verbal irony we often convey meanings that oppose the literal words. To look behind these words, we need to integrate perspectives of ourselves, others, and their beliefs about us. Although patients with borderline personality disorder (BPD) experience problems in social cognition and schizotypal symptoms, research on irony comprehension mainly focused on the schizophrenic spectrum. Accounting for possible negative biases in BPD, the current study examined the detection of praising and critical irony in a text messaging interface.

METHODS

The cross-sectional study included 30 patients and 30 matched controls, who completed measures of cognitive and affective empathy (Interpersonal Reactivity Index, IRI), schizotypal (Schizotypal Personality Questionnaire; SPQ), and borderline symptoms (Borderline Symptom List; BSL-23) and the irony detection task. The irony task contained critical and praising remarks embedded in text messages. Asking for literality (ironic vs. literal) and intention ratings (critical to praising) of the stimuli, it allowed to analyze the sensitivity of literality detection as well as implicit and explicit response biases in a signal detection framework.

RESULTS

Borderline symptoms explained lower sensitivity for the detection of literal and ironic statements across groups. Whereas HC showed a negativity bias when implicitly asked about the literalness of the statement, patients with BPD perceived praising utterances as less praising when explicitly asked about their perceived intention. Neither empathy nor schizotypy explained outcomes beyond borderline symptoms.

CONCLUSIONS

This was the first study to show lower detection of verbal irony in patients with BPD. While patients were less biased when asked about the literality of a statement, they perceived praising remarks as less positive on explicit measurements. The results highlight the importance of congruent, transparent communication in promoting epistemic trust in individuals with BPD.

Hypermentalizing and Borderline Personality Disorder: A Meta-Analytic Review

OBJECTIVE

A hypermentalizing impairment, or tendency to overattribute mental states to others, has been identified among individuals with borderline personality disorder. However, associations between hypermentalizing and other disorders call into question the specificity of this impairment to borderline personality disorder. This study aimed to evaluate the relative strength of the association between hypermentalizing and borderline personality disorder compared with other disorders and to assess the impact of moderators on the relationship between hypermentalizing and psychopathology.

METHODS

The authors conducted a meta-analysis of 36 studies (N=4,188 people) to investigate the relative strength of the association between hypermentalizing and borderline personality disorder, compared with other disorders, and to assess the impact of moderators on this relationship. The Movie for the Assessment of Social Cognition, an ecologically valid experimental instrument, was used to measure hypermentalizing.

RESULTS

Results indicated support for an association between psychopathology and hypermentalizing (r=0.24, 95% confidence interval [CI]=0.17 to 0.31), but the association was not significantly stronger for borderline personality disorder (r=0.26, 95% CI=0.12 to 0.39) than for other disorders (r=0.24, 95% CI=0.14 to 0.33). Neither age nor gender significantly moderated the association between psychopathology and hypermentalizing.

CONCLUSIONS

Hypermentalizing may be related to psychopathology in general rather than borderline personality disorder in particular. The findings are discussed in view of the possibility that features of borderline personality disorder associated with other psychopathology may explain the overall association between psychopathology and hypermentalizing. Clinical implications for mentalization-based treatment and concerns that the measurement used for hypermentalization may be too narrow and not representative of variations in functioning across cultures and race-ethnicity also are discussed.

Affective and cognitive theory of mind in posttraumatic stress, major depressive, and somatic symptom disorders: Association with childhood trauma

OBJECTIVES

Childhood trauma constitutes a major risk factor for adult psychopathology, including posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and somatic symptom disorder (SSD). One potential mechanism linking childhood trauma to adult psychopathology may be alterations in theory of mind (ToM). Given the lack of transdiagnostic studies on the association between childhood trauma and ToM, further research is needed to elucidate whether and how childhood trauma relates to ToM impairments across and within diagnostic boundaries.

DESIGN

A cross-sectional study design was applied.

METHODS

A total of 137 individuals with varying levels of childhood trauma took part in this study, encompassing individuals with PTSD (n = 33), MDD (n = 33), SSD (n = 36), and healthy volunteers (HVs; n = 35). To assess ToM performance and childhood trauma, the Movie for the Assessment of Social Cognition was administered along with the Childhood Trauma Questionnaire.

RESULTS

Only individuals with PTSD, but not individuals with MDD or SSD, showed a worse ToM performance compared to HVs. In the whole sample, childhood trauma correlated negatively with ToM performance. Exploratory group-specific analyses revealed higher levels of childhood trauma to be associated with more excessive ToM errors in individuals with SSD, and notably with an enhanced ToM performance in individuals with MDD.

CONCLUSIONS

Our results indicate associations between childhood trauma and ToM impairments in a large, transdiagnostic sample. Provided replication in future studies, our findings suggest ToM capacities as a promising treatment target for individuals exposed to severe childhood trauma, at least or particularly with a diagnosis of PTSD.

PRACTITIONER POINTS

Our results suggest that individuals with a history of severe childhood trauma, at least or particularly with a clinical diagnosis of posttraumatic stress disorder, may benefit from therapeutic approaches targeting theory of mind capacities. Our findings indicate that higher levels of childhood trauma may be linked to a specific 'hypermentalizing' bias in somatic symptom disorder. Our findings further point towards an association between higher levels of childhood trauma and a heightened - rather than a diminished - sensitivity towards interpersonal cues in major depressive disorder. Provided further confirmatory evidence, our findings may support diagnosis-specific approaches in ameliorating theory of mind abilities in individuals with different mental disorders and a history of severe childhood trauma.

Investigation of the Factor Structure of the Reflective Functioning Questionnaire (RFQ-8): One or Two Dimensions?

There is a need to have reliable and accessible screening measures of mentalizing ability to investigate the role of this capacity in social functioning and its development, emergence of psychopathological conditions, as well as to understand its role in psychotherapeutic processes. The 8-itemed Reflective Functioning Questionnaire (RFQ-8) has been developed for this purpose, however its factor structure and psychometric properties are unclear. The aim of the current study was to further investigate the factor structure of the RFQ-8 and explore its psychometric properties in a Polish sample. 538 participants aged 17-50 (M = 21.44, SD = 2.92) took part in the study. They were asked to complete the RFQ-8, Difficulties in Emotion Regulation Scale (DERS), General Health Questionnaire (GHQ-28), the Relationship Structures (ECR-RS) questionnaire and the Borderline Personality Inventory (BPI). Results of both exploratory and confirmatory analysis indicated that the RFQ-8 may be regarded as a scale measuring a unidimensional construct. Our results confirmed good construct validity for the unidimensional RFQ-8, suggesting that the one-dimensional RFQ specifically assesses uncertainty concerning mental states. Our findings highlight the need for further studies investigating the factor structure and psychometric properties of the RFQ-8.

Affective theory of the mind and suicide in women with borderline personality disorder and schizophrenia: a comparative study

Background

Theory of mind (ToM) is one of the essential components of social cognition. Affective ToM enables us to interpret other’s feelings and behaviors. Borderline personality disorder (BPD) and schizophrenia are two distinct mental disorders, yet they have a mutual deficit in interpreting emotions, thoughts, and intentions which may lead to a higher incidence of suicidality. Studies that involved social cognition, particularly ToM in schizophrenia, or BPD have controversial results. Therefore, this study aimed at comparing affective ToM functioning in female patients with BPD, schizophrenia, and healthy controls. In addition, identifying the possible impact and any correlation exists between the affective ToM and liability for suicide in those patients. Sixty individuals were recruited from the Institute of Psychiatry, Ain Shams University, Cairo, Egypt, and assigned into 3 groups where group A involved 20 BPD patients, group B involved 20 schizophrenic patients, and group C were healthy persons as a control. Assessment of affective ToM was done using Reading the Mind in the Eyes Test (RMET), and probability of suicide was measured using Suicide Probability Scale (SPS).

Results

Regarding ToM, the three groups were assessed using RMET and the results revealed a significantly higher mean score (hypermentalization) in BPD patients than both schizophrenic patients and controls. While schizophrenic patients had significantly lower mean scores than the control group (hypomentalization). As well, BPD patients had a significantly higher suicide probability total score than Schizophrenic patients and in all subdomains except for the hostility subdomain that was significantly higher in schizophrenic patients. Interestingly, in BPD, the suicide probability total score was positively correlated with RMET.

Conclusions

BPD patients have enhanced affective ToM and hypermentalization that is significantly associated with increased suicide probability in those patients, while in schizophrenia, hypomentalization could not be linked to increased suicide probability. Rehabilitation and proper management of ToM abnormalities might be a crucial tool in suicide prevention in mental illnesses, particularly, BPD.

The conceptualization and assessment of social cognition in personality and common mental disorders

Social Cognition is a crucial transdiagnostic construct with clinical and functional relevance across a range of neuropsychiatric disorders. Most research has focused on schizophrenia and autism spectrum disorders and has informed frameworks for assessing social cognition in schizophrenia. The current review focuses on the more recent developments pertaining to personality and common mental disorders (PCMDs). Two main questions are addressed: 1. What are the important domains and patterns of social cognition impairments among the personality and common mental disorders? 2. What are the trends in the assessment of social cognition among personality and common mental disorders? We synthesize research findings on the conceptualization of SC and the application of these frameworks for assessment with PCMDs. We have outlined a typology of criteria and guidelines for selecting and developing measures of SC in the PCMDs. We conclude that there is a need for a reconceptualization of social cognition or PCMDs with a focus on higher-order processes and suggest that mentalization could be a suitable framework to understand and examine social cognition in the PCMDs. Future efforts to develop, adapt and use more complex, nuanced, sensitive, and culturally valid measures of social cognition in interpersonal contexts can aid the detection of subtle, context-dependent, and dynamic impairments across these disorders. Social cognition is a promising transdiagnostic construct and warrants more conceptual clarity and research on the varied patterns of impairments across disorders.

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.

Cognitive and Affective Theory of Mind in Female Patients With Borderline Personality Disorder

Empirical studies have identified deficits in cognitive and affective theory of mind (ToM) in patients with borderline personality disorder (BPD), but results remain heterogeneous and not much is known about the role of childhood trauma. The current study assessed cognitive and affective ToM in 80 patients with BPD and 41 healthy controls in a false-belief cartoon task. Childhood trauma was measured with the Childhood Trauma Questionnaire (CTQ). Patients with BPD responded slower in all experimental conditions in false-belief situations, but not when false beliefs were resolved; made more errors in the cognitive ToM condition; and reported worse affective states more often in and after false-belief situations. No significant correlations between ToM and childhood trauma could be found. The current study revealed deficits in cognitive and affective ToM in patients with BPD that may be related to a more negative affective state raised by the false-belief stories.

Cognitive and Affective Theory of Mind in Positive Schizotypy: Relationship to Schizotypal Traits and Psychosocial Functioning

Theory of mind (ToM) impairments are well documented in schizophrenia, although it remains unclear whether these deficits exist among individuals with schizotypy. The current study sought to shed light on mixed findings in schizotypy by differentiating between various aspects of ToM, (cognitive/affective ToM and overmentalization/undermentalization). A three-group design (positive schizotypy, negative affect, and healthy control) was used to assess ToM performance on the Movie for Assessment of Social Cognition. Results indicated that the positive schizotypy group made greater intent overmentalization errors than both control groups. The schizotypy and negative affect groups made greater emotion overmentalization errors relative to healthy controls. In addition, the authors explored the relationship between ToM, schizotypal traits, and psychosocial functioning. Results demonstrated a significant positive relationship between cognitive-perceptual schizotypal traits and intent overmentalization as well as a significant positive relationship between interpersonal traits and emotion overmentalization. Finally, intent and emotion overmentalization were both related to poorer psychosocial functioning.

Cortical thickness distinguishes between major depression and schizophrenia in adolescents

BACKGROUND

Early diagnosis of adolescent psychiatric disorder is crucial for early intervention. However, there is extensive comorbidity between affective and psychotic disorders, which increases the difficulty of precise diagnoses among adolescents.

METHODS

We obtained structural magnetic resonance imaging scans from 150 adolescents, including 67 and 47 patients with major depressive disorder (MDD) and schizophrenia (SCZ), as well as 34 healthy controls (HC) to explore whether psychiatric disorders could be identified using a machine learning technique. Specifically, we used the support vector machine and the leave-one-out cross-validation method to distinguish among adolescents with MDD and SCZ and healthy controls.

RESULTS

We found that cortical thickness was a classification feature of a) MDD and HC with 79.21% accuracy where the temporal pole had the highest weight; b) SCZ and HC with 69.88% accuracy where the left superior temporal sulcus had the highest weight. Notably, adolescents with MDD and SCZ could be classified with 62.93% accuracy where the right pars triangularis had the highest weight.

CONCLUSIONS

Our findings suggest that cortical thickness may be a critical biological feature in the diagnosis of adolescent psychiatric disorders. These findings might be helpful to establish an early prediction model for adolescents to better diagnose psychiatric disorders.

An exploration of theory of mind performance among men convicted of rape

Several of the known risk factors for sexual violence concern a lack of capacity for engaging in mutually satisfying interpersonal relationships. Socio-cognitive deficits may be approached from a theory of mind (ToM) perspective, where lack of ability to attribute mental states to others is seen as the core feature. This study focuses on imprisoned men (n = 26) convicted of rape against an adult. A video-based measure of ToM (MASC) was applied, depicting social interaction in a dynamic real-life setting. The results showed that the rape-convicted men have a markedly inferior ability to infer the mental states of others. Clinical as well as theoretical implications of the findings are discussed.

Are Impairments in Theory of Mind Specific to Borderline Personality Disorder?

Impaired theory of mind (ToM) is an assumed feature of borderline personality disorder (BPD). Yet, no studies have compared ToM abilities in patients with BPD, other personality disorders, and healthy controls, or investigated the relationship between ToM and severity of psychopathology and interpersonal problems. In this study, ToM was investigated by the Movie for the Assessment of Social Cognition. No differences were found between the three groups in overall ToM abilities. The BPD group was, however, characterized by more excessive ToM (interpreted as hypermentalization). Yet, when differentiating between BPD and further severity indicators, excessive ToM was not specifically associated with a BPD diagnosis per se. Finally, there was a moderate association between hypermentalization and interpersonal problems in the BPD group. This study suggests that BPD patients tend to hypermentalize when they misinterpret social information, and that this tendency is related to the severity of their psychopathology.

Sexual abuse and physical neglect in childhood are associated with affective theory of mind in adults with schizophrenia

Whereas childhood trauma is associated with reduced nonsocial cognition in schizophrenia, research on the relationship between childhood trauma and social cognition is limited and mixed. The aim of this study was to examine the association between childhood trauma and theory of mind (ToM) in persons with schizophrenia (n = 68) compared to healthy control participants (n = 70). Childhood trauma was assessed with the Childhood Trauma Questionnaire (CTQ), providing information on physical abuse, emotional abuse, sexual abuse, physical neglect and emotional neglect. ToM was indexed by the Movie for the Assessment of Social Cognition (MASC), which yields scores for total, cognitive and affective ToM, and for three error types (overmentalizing, undermentalizing, no mentalizing). Persons with schizophrenia had elevated rates of childhood trauma and lower ToM scores than healthy controls. In the schizophrenia group, associations between sexual abuse and affective ToM was statistically significant. In regression analyses, physical neglect was found to be the strongest predictor of affective ToM. In healthy controls, childhood trauma was not associated with ToM. Follow-up analyses comparing individuals with/without clinically significant childhood trauma, confirmed the findings for the schizophrenia group. No causal inferences can be made in this cross-sectional study, but the results suggest an illness-specific association between both sexual abuse and physical neglect in childhood, and adult affective ToM in individuals with schizophrenia.

Familiarity, empathy and comprehension of metaphors in patients with borderline personality disorder

Research on figurative language has a long tradition in psychiatry, as it is employed in psychotherapy and its (mis)comprehension plays a substantial role in differential diagnostics of schizophrenic spectrum disorders. Although often associated with empathy and mentalization, it has never been addressed in borderline personality disorder (BPD). Therefore, this study investigated metaphor comprehension and its relationship to cognitive and affective empathy in 20 patients with BPD and 20 matched healthy controls who completed a metaphor task comprising conventional metaphors (CM), novel metaphors (NM), meaningless stimuli (MS), and a rating scale of familiarity, a factor known to influence performance. For cognitive and affective empathy, the interpersonal reactivity index was applied. At first patients with BPD seemed to have significantly more problems in comprehending CM, but not NM or MS, and were less familiar with CM. When familiarity with the stimulus was controlled, this difference disappeared. As for empathy, only fantasy was positively related to familiar CM beyond borderline symptoms. Results indicate that the comprehension of novel metaphorical meaning is preserved in patients with BPD.

Implicit and Explicit Mentalizing Deficits in Adolescent Inpatients: Specificity and Incremental Value of Borderline Pathology

Research has demonstrated mentalizing impairment associated with borderline personality disorder (BPD) in adolescents. However, mentalizing performance in adolescents with BPD has never been compared to that of psychiatric control and healthy control adolescents simultaneously. The present study aimed to (a) compare implicit and explicit mentalizing, and hypermentalizing errors in implicit mentalizing, across youth with BPD and psychiatric and healthy controls, and (b) evaluate the association of borderline features with mentalizing deficits over and above internalizing and externalizing. Psychiatric inpatients with BPD (n = 139), inpatient psychiatric controls (n = 310), and healthy adolescents (n = 134) completed two mentalizing tasks, an interview assessing BPD, and measures of psychopathology. Results showed that BPD specificity could be demonstrated only for implicit mentalizing and hypermentalizing. Explicit mentalizing deficits did not differ between BPD and psychiatric control groups. Borderline features had unique associations to implicit mentalizing and hypermentalizing, over and above internalizing and externalizing.

Rapid facial mimicry responses are preserved in youth with first presentation borderline personality disorder

BACKGROUND

Empathy is a complex and multifaceted construct comprising cognitive and affective components. Abnormal empathic responses are implicated in borderline personality disorder (BPD). Specifically, unconscious motor mimicry (a primitive component of affective empathy evident from infancy) is theorized to be heightened and to contribute to the heightened emotional contagion often seen in people with BPD. Yet, no study has directly tested whether abnormally heightened unconscious motor mimicry is associated with BPD features or whether this is present early in the course of BPD.

METHODS

In the present study, facial electromyography was used to assess the rapid facial mimicry responses (a form of unconscious motor mimetic responding) of 32 outpatient youths (aged 15-25 years) with early stage BPD features and 47 demographically matched healthy control participants (HC).

RESULTS

The results showed no group differences in rapid facial mimetic responses to either positive (happy) or negative (angry) facial emotions.

LIMITATIONS

Co-occurring psychopathology and the potential impact of state affect on rapid facial mimicry were considered and discussed.

CONCLUSIONS

These data indicate that there is no evidence for abnormally heightened rapid motor mimicry in youth early in the course of BPD, suggesting that rapid facial mimicry is preserved in this group. It is thus unlikely that abnormally heightened unconscious simulation contributes to heightened emotional contagion in youth with first presentation BPD. Future research should explore alternative mechanisms for this phenomenon and also whether abnormalities in motor mimetic responses are evident in later stages of the disorder.

Social Cognition Capacities as Predictors of Outcome in Mentalization-Based Treatment (MBT)

BACKGROUND

Mentalization-based treatment (MBT) is an evidence-based treatment for borderline personality disorder (BPD). Differences in treatment outcomes related to specific capacity of social cognition need further attention. This study aimed to investigate social cognition as a predictor of outcome.

METHOD

The study included 31 BPD patients who completed a test of social cognition (Movie for the Assessment of Social Cognition, MASC) before outpatient MBT. The MASC-scores indicated a person's theory of mind (ToM) and different error-types. During treatment repeated self-reports of alliance and clinical outcomes (symptoms, interpersonal problems, social functioning) were applied. Longitudinal analyses were based on Linear Mixed Models (n = 24).

RESULTS

The most frequent error-type was excessive ToM (hypermentalizing). Higher levels of excessive ToM were associated with greater improvement of alliance over time and good clinical outcomes. Insufficient ToM errors and low levels of accurate cognitive ToM responses were both associated with poorer improvement over time. The subgroup with frequent insufficient ToM errors had a larger total number of ToM errors. Insufficient ToM errors were associated with more childhood trauma, comorbid avoidant PD traits and/or PTSD, extensive prior treatment, and/or treatment irregularity.

CONCLUSION

This study demonstrates considerable variation of social cognitive capacity among BPD patients and good outcomes for patients with mainly ToM errors of hypermentalizing. It also indicates that poorly responding patients may represent a cohort with more complex problems of social cognition and insufficient mentalizing.

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.

Cognitive-Emotional and Inhibitory Deficits as a Window to Moral Decision-Making Difficulties Related to Exposure to Violence

In the present review, we illustrate how exposure to violence results in an increased probability of developing functional impairments of decision mechanisms necessary for moral behavior. We focus in particular on the detrimental effects of exposure to violence on emotional (e.g., Empathy), cognitive (e.g., Theory of Mind), and inhibitory control abilities. Relying on studies that document impaired moral behavior in individuals with deficits in these abilities, we propose a "model" of how exposure to violence can affect moral behavior. We then discuss how impaired moral decision making can also be a factor increasing the likelihood of reiterating violence: agents who lack abilities such as understanding and resonating with others' emotions or inhibitory control, can lead to an increase of violent displays. Thus, if not properly addressed, the noxious effects of exposure to violence on morality can lead to a violence generating cycle. We conclude proposing that interventions targeted at improving moral behavior can maximize their efficacy focusing on mitigating the impact of violence on the basic cognitive, emotional, and inhibitory abilities discussed.

Perspective Change and Personality State Variability: An Argument for the Role of Self-Awareness and an Outlook on Bidirectionality (Commentary on Wundrack et al., 2018)

In a recent article, Wundrack et al. (2018) put forward an elaborate and intriguing hypothesis on enhanced perspective-taking (Theory of Mind) ability as a consequence of higher personality state variability. While there is evidence in favor of this hypothesis, the clinical examples of bipolar disorder and borderline personality disorder, as highlighted by the authors, demonstrate that a high state variability can also be accompanied by a lower perspective-taking ability (as commonly observed in these disorders). We suggest that only those state changes which are initiated on a voluntary basis and are accompanied by self-awareness go along with a higher perspective-taking ability. Introducing self-awareness as a moderating factor might help explain seemingly conflicting findings related to the hypothesis proposed in the target article. Moreover, we argue that the direction of causality proposed in the target article is not the only conceivable one, and perspective-taking ability could also be a cause, not just a consequence, of personality state variability. Finally, we provide suggestions on how these hypotheses could be tested in future studies.

Mentalization in Adolescents With Borderline Personality Disorder: A Comparison With Healthy Controls

Mentalization is proposed to underlie the disturbed interpersonal relatedness that is a hallmark of borderline personality disorder (BPD). Despite growing evidence of BPD in adolescents, studies examining mentalization in relation to adolescent BPD have remained limited. Given contradictory findings of this relationship, particularly with adults, further research of mentalization in adolescents with BPD is warranted. The current study further clarifies the nature of mentalizing impairments, related to BPD, by examining different aspects of mentalization between adolescents with BPD (n = 26) and a group of healthy controls (n = 25). Findings support studies that suggest that mentalization may be an important treatment target, influencing BPD symptoms and interpersonal functioning in adolescents with BPD. They also support the importance of examining mentalizing abilities in relation to varying levels of complexity, interpersonal contexts, and levels of arousal. Limitations and further research are discussed.

Mentalization-based treatment or psychodynamic treatment programmes for patients with borderline personality disorder - the impact of clinical severity

OBJECTIVES

Mentalization-based treatment (MBT), originally designed for patients with borderline personality disorder (BPD), may be particularly indicated for severe conditions. However, there is limited documentation of how increasing severity of personality disorder (PD) effect outcomes of highly specialized treatments. This study aimed to investigate associations between clinical severity and outcomes for patients in MBT as compared to a psychodynamic group-based treatment programme (PDT).

DESIGN

A naturalistic, longitudinal, comparison study.

METHODS

The sample included 345 patients with BPD (PDTn = 281, MBTn = 64). The number of diagnosed PDs, PD criteria, and symptom disorders were chosen as baseline indicators of clinical severity. Clinical outcomes (global functioning, symptom distress, interpersonal problems) were repeatedly assessed over three years. Therapists' fidelity to MBT was satisfactory. Linear mixed models were the applied statistics.

RESULTS

In PDT, greater clinical severity was associated with poorer improvement rates. Clinical severity was not associated with significant differences in outcomes for patients in MBT. Differences in outcomes for patients in MBT and PDT increased significantly with higher severity of disorder.

CONCLUSIONS

Supporting previous research, this study indicates that clinical benefits associated with MBT also apply for BPD patients with severe conditions. The results also suggest that increasing severity was a challenge in PDT.

PRACTITIONER POINTS

MBT may be particularly beneficial for severely disordered BPD patients Differences between MBT and PDT were less pronounced in moderately disordered BPD patients.

Abnormalities in functional connectivity in borderline personality disorder: Correlations with metacognition and emotion dysregulation

A few studies reported functional abnormalities at rest in borderline personality disorder (BPD), but their relationship with clinical aspect is unclear. We aimed to assess functional connectivity (FC) in BPD patients and its association with BPD clinical features. Twenty-one BPD patients and 14 healthy controls (HC) underwent a multidimensional assessment and resting-state fMRI. Independent component analysis was performed to identify three resting-state networks: default mode network (DMN), salience network (SN), and executive control network (ECN). FC differences between BPD and HC were assessed with voxel-wise two-sample t-tests. Additionally, we investigated the mean FC within each network and the relationship between connectivity measures and BPD clinical features. Patients showed significant lower mean FC in the DMN and SN, while, at the local level, a cluster of lower functional connectivity emerged in the posterior cingulate cortex of the DMN. The DMN connectivity was positively correlated with the anger-state intensity and expression, while the SN connectivity was positively correlated with metacognitive abilities and a negative correlation emerged with the interpersonal aggression. The dysfunctional connectivity within these networks might explain clinical features of BPD patients.

Effects of Childhood Maltreatment on Social Cognition and Brain Functional Connectivity in Borderline Personality Disorder Patients

Borderline personality disorder (BPD) is a chronic condition characterized by high levels of impulsivity, affective instability, and difficulty to establish and manage interpersonal relationships. However, little is known about its etiology and neurobiological substrates. In our study, we wanted to investigate the influence of child abuse in the psychopathology of BPD by means of social cognitive paradigms [the Movie for the Assessment of Social Cognition (MASC) and the reading the mind in the eyes test (RMET)], and resting state functional magnetic resonance imaging (rs-fMRI). For this, we recruited 33 participants, 18 BPD patients, and 15 controls. High levels of self-reported childhood maltreatment were reported by BPD patients. For the sexual abuse subdimension, there were no differences between the BPD and the control groups, but there was a negative correlation between MASC scores and total childhood maltreatment levels, as well as between physical abuse, physical negligence, and MASC. Both groups showed that the higher the level of childhood maltreatment, the lower the performance on the MASC social cognitive test. Further, in the BPD group, there was hypoconnectivity between the structures responsible for emotion regulation and social cognitive responses that have been described as part of the frontolimbic circuitry (i.e., amygdala). Differential levels of connectivity, associated with different types and levels of abuse were also observed.

Theory of mind disturbances in borderline personality disorder: A meta-analysis

Impairments of theory of mind (ToM) are widely accepted underlying factors of disturbed relatedness in borderline personality disorder (BPD). The aim of this meta-analysis a was to assess the weighted mean effect sizes of ToM performances in BPD compared to healthy controls (HC), and to investigate the effect of demographic variables and comorbidities on the variability of effect sizes across the studies. Seventeen studies involving 585 BPD patients and 501 HC were selected after literature search. Effect sizes for overall ToM, mental state decoding and reasoning, cognitive and affective ToM, and for task types were calculated. BPD patients significantly underperformed HC in overall ToM, mental state reasoning, and cognitive ToM, but had no deficits in mental state decoding. Affective ToM performance was largely task dependent in BPD. Comorbid anxiety disorders had a positive moderating effect on overall and affective ToM in BPD. Our results support the notion that BPD patients' have specific ToM impairments. Further research is necessary to evaluate the role of confounding factors, especially those of clinical comorbidities, neurocognitive functions, and adverse childhood life events. Complex ToM tasks with high contextual demands seem to be the most appropriate tests to assess ToM in patients with BPD.

An investigation of the mentalization-based model of borderline pathology in adolescents

OBJECTIVE

According to mentalization-based theory, transgenerational transmission of mentalization from caregiver to offspring is implicated in the pathogenesis of borderline personality disorder (BPD). Recent research has demonstrated an association between hypermentalizing (excessive, inaccurate mental state reasoning) and BPD, indicating the particular relevance of this form of mentalizing dysfunction to the transgenerational mentalization-based model. As yet, no study has empirically assessed a transgenerational mentalization-based model of BPD. The current study sought firstly to test the mentalization-based model, and additionally, to determine the form of mentalizing dysfunction in caregivers (e.g., hypo- or hypermentalizing) most relevant to a hypermentalizing model of BPD.

METHOD

Participants were a mixed sample of adolescents with BPD and a sample of non-clinical adolescents, and their respective primary caregivers (n = 102; 51 dyads). Using an ecologically valid measure of mentalization, mediational analyses were conducted to examine the relationships between caregiver mentalizing, adolescent mentalizing, and adolescent borderline features.

RESULTS

Findings demonstrated that adolescent mentalization mediated the effect of caregiver mentalization on adolescent borderline personality pathology. Furthermore, results indicated that hypomentalizing in caregivers was related to adolescent borderline personality pathology via an effect on adolescent hypermentalizing.

CONCLUSIONS

Results provide empirical support for the mentalization-based model of BPD, and suggest the indirect influence of caregiver mentalization on adolescent borderline psychopathology. Results further indicate the relevance of caregiver hypomentalizing to a hypermentalizing model of BPD.

Reviving pragmatic theory of theory of mind

Theory of Mind (ToM) refers to the ability to attribute mental states to self and others. It has been debated whether or not language capacity precedes ToM in development. Evidence from both neurological and developmental studies suggested that while linguistic capacity is important for ToM understanding, pragmatic component, which is a non-structural part of language, is more important for ToM. Moreover, given that pragmatic component of language is subserved by the right hemisphere of the brain, the evidence also indicates a significant overlap between the neural basis of ToM and that of pragmatic comprehension. The pragmatic theory of ToM, which I aim to revive in this review, firmly links pragmatics to ToM. It regards pragmatic aspects of language and ToM as extensively overlapping functions. I argue that research results from both developmental and neurological studies of ToM are beginning to converge to support this theory. Furthermore, I maintain that the pragmatic theory of ToM provides the best explanation for the seemingly incongruent results from recent child and infant studies on the developmental trajectory of ToM. Lastly, I will discuss whether this theory is in agreement with the domain-specific, the nativist framework, or neither.

Pattern of social cognition deficits in individuals with borderline personality disorder

BACKGROUND

Social cognition deficits have been implicated in the affect regulation and interpersonal difficulties seen in borderline personality disorder (BPD). The study examined patterns of social cognition abilities, using self-report and task-based measures, among individuals diagnosed with BPD.

METHODS

The sample included a clinical group of 20 patients diagnosed with BPD and 20 age and gender-matched control group participants from the community with no psychiatric diagnosis. The measures included the Mentalization Questionnaire, the Reading the Mind in the Eyes Test and the Social Cognition Rating Tool in Indian Setting.

RESULTS

Results indicated that the clinical group had lower self-reported mentalizing ability. Facial emotion recognition ability was significantly lower for the clinical group, particularly for photographs of the eye region with positive and neutral valences. The clinical group had significantly higher personalizing bias, and greater difficulties in social perception. The two groups did not differ on first and second order theory of mind, recognition of faux pas and externalizing bias.

CONCLUSIONS

The results point to the links between social cognition deficits and interpersonal difficulties among persons with BPD. Implications include the need for pre-therapy assessment of the magnitude and patterns of social cognition difficulties in BPD, the development of culturally and ecologically valid assessments and the evaluation of interventions for social cognition vulnerabilities among individuals with BPD.

Affective and cognitive theory of mind abilities in youth with borderline personality disorder or major depressive disorder

BACKGROUND

Theory of mind (ToM) is an important social cognitive ability that has been investigated in BPD, with inconsistent findings indicating impaired, comparable, and enhanced ToM in BPD. This study aimed to clarify and extend previous findings by investigating affective and cognitive ToM abilities in youth early in the course of BPD, by including a clinical comparison group of youth with major depressive disorder (MDD).

METHODS

Female participants aged 15-24 years diagnosed with BPD (n = 41) or MDD (n = 37) completed the Reading the Mind in the Eyes Test (RMET) and Happé's Cartoon Task, measures of affective and cognitive dimensions of ToM, respectively.

RESULTS

The BPD group performed significantly worse than the MDD group on the affective ToM task, even after controlling for age, intelligence and depressive symptoms. Results for cognitive ToM were not significantly different.

CONCLUSIONS

Finding of poorer performance on a measure of affective ToM, in BPD youth, relative to youth with MDD early in the course of BPD suggest a developmental failure of sociocognitive abilities needed for mentalising and which are theorised as giving rise to core features of BPD. Future research should employ more naturalistic paradigms to study social cognition and should assess individuals even earlier in the course of BPD.

On the relationships between DSM-5 dysfunctional personality traits and social cognition deficits: A study in a sample of consecutively admitted Italian psychotherapy patients

This study aims at testing the hypothesis that the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) alternative model of personality disorder (AMPD) traits may be significantly associated with deficits on 2 different social cognition tasks, namely, the Reading the Mind in the Eyes Test and the Movie for the Assessment of Social Cognition, in a sample of consecutively admitted inpatients and outpatients. The sample was composed of 181 consecutively admitted participants (57.5% women; mean age = 38.58 years). Correlation coefficients and partial correlation coefficients were computed in order to assess the associations among social cognition tasks, DSM-5 AMPD traits, and dimensionally assessed DSM-5 Section II personality disorders. Specific maladaptive traits listed in the DSM-5 AMPD were significantly associated with Reading the Mind in the Eyes Test scores and Movie for the Assessment of Social Cognition scores, even when the effect of selected DSM-5 Section II personality disorders was controlled for. Our results support the relevance of studying social cognitive functioning in subjects suffering from personality disorders.