Hostname: page-component-cd9895bd7-mkpzs Total loading time: 0 Render date: 2024-12-26T05:52:55.911Z Has data issue: false hasContentIssue false
  • English
  • Français

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

Published online by Cambridge University Press:  17 September 2021

Emre Bora Open the ORCID record for Emre Bora [Opens in a new window]
Emre Bora*
Affiliation:
Department of Psychiatry, Dokuz Eylul University Medical School, Izmir35340, Turkey Department of Neurosciences, Insitiute of Health, Dokuz Eylul University, Izmir, Turkey Department of Psychiatry, Melbourne Neuropsychiatry Centre, University of Melbourne and Melbourne Health, Carlton South, Victoria3053, Australia
*
Author for correspondence: Emre Bora, E-mail: emre.bora@deu.edu.tr, ibora@unimelb.edu.au
Get access Rights & Permissions [Opens in a new window]

Abstract

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.

Keywords

Borderline personality disordermentalizationreflective functioningsocial cognitiontheory of mind
Type
Review Article
Information
Psychological Medicine , Volume 51 , Issue 15 , November 2021 , pp. 2541 - 2551
Check for updates
Copyright
Copyright © The Author(s), 2021. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Association.Google Scholar
Andreou, C., Kelm, L., Bierbrodt, J., Braun, V., Lipp, M., Yassari, A. H., & Moritz, S. (2015). Factors contributing to social cognition impairment in borderline personality disorder and schizophrenia. Psychiatry Research, 229, 872–879.CrossRefGoogle Scholar
Anupama, V., Bhola, P., Thirthalli, J., & Mehta, U. M. (2018). Pattern of social cognition deficits in individuals with borderline personality disorder. Asian Journal of Psychiatry, 33, 105–112.CrossRefGoogle ScholarPubMed
Arntz, A., Bernstein, D., Oorschot, M., & Schobre, P. (2009). Theory of mind in borderline and cluster-C personality disorder. The Journal of Nervous and Mental Disease, 197, 801–807.CrossRefGoogle ScholarPubMed
Badoud, D., Prada, P., Nicastro, R., Germond, C., Luyten, P., Perroud, N., & Debbané, M. (2018). Attachment and reflective functioning in women with borderline personality disorder. Journal of Personality Disorders, 32, 17–30.CrossRefGoogle ScholarPubMed
Baez, S., Marengo, J., Perez, A., Huepe, D., Font, F. G., Rial, V., … Ibanez, A. (2015). Theory of mind and its relationship with executive functions and emotion recognition in borderline personality disorder. Journal of Neuropsychology, 9, 203–218.CrossRefGoogle ScholarPubMed
Baron-Cohen, S., Wheelwright, S., Hill, J., Raste, Y., & Plumb, I. (2001). The “reading the mind in the eyes” test revised version: A study with normal adults, and adults with Asperger syndrome or high-functioning autism. Journal of Child Psychology and Psychiatry, 42, 241–251.CrossRefGoogle ScholarPubMed
Bateman, A., & Fonagy, P. (2003). The development of an attachment-based treatment program for borderline personality disorder. Bulletin of the Menninger Clinic, 67, 187–211.CrossRefGoogle ScholarPubMed
Bateman, A., & Fonagy, P. (2009). Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry, 166, 1355–1364.CrossRefGoogle ScholarPubMed
Bateman, A., & Fonagy, P. (2010). Mentalization based treatment for borderline personality disorder. World Psychiatry, 9, 11–15.CrossRefGoogle ScholarPubMed
Berenson, K. R., Dochat, C., Martin, C. G., Yang, X., Rafaeli, E., & Downey, G. (2018). Identification of mental states and interpersonal functioning in borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 9, 172–181.CrossRefGoogle ScholarPubMed
Bora, E., & Berk, M. (2016). Theory of mind in major depressive disorder: A meta-analysis. Journal of Affective Disorders, 191, 49–55.CrossRefGoogle ScholarPubMed
Bora, E., & Köse, S. (2016). Meta-analysis of theory of mind in anorexia nervosa and bulimia nervosa: A specific impairment of cognitive perspective taking in anorexia nervosa? International Journal of Eating Disorders, 49, 739–740.CrossRefGoogle ScholarPubMed
Bora, E., Özakbaş, S., Velakoulis, D., & Walterfang, M. (2016). Social cognition in multiple sclerosis: A meta-analysis. Neuropsychology Review, 26, 160–172.CrossRefGoogle ScholarPubMed
Bora, E., & Pantelis, C. (2016). Meta-analysis of social cognition in attention-deficit/hyperactivity disorder (ADHD): Comparison with healthy controls and autistic spectrum disorder. Psychological Medicine, 46, 699–716.CrossRefGoogle ScholarPubMed
Bora, E., Walterfang, M., & Velakoulis, D. (2015). Theory of mind in behavioural-variant frontotemporal dementia and Alzheimer's disease: A meta-analysis. Journal of Neurology, Neurosurgery, and Psychiatry, 86, 714–719.CrossRefGoogle ScholarPubMed
Brüne, M., Walden, S., Edel, M. A., & Dimaggio, G. (2016). Mentalization of complex emotions in borderline personality disorder: The impact of parenting and exposure to trauma on the performance in a novel cartoon-based task. Comprehensive Psychiatry, 64, 29–37.CrossRefGoogle Scholar
Carcione, A., Riccardi, I., Bilotta, E., Leone, L., Pedone, R., Conti, L., … Semerari, A. (2019). Metacognition as a predictor of improvements in personality disorders. Frontiers in Psychology, 10, 170.CrossRefGoogle ScholarPubMed
Chung, Y. S., Barch, D., & Strube, M. (2014). A meta-analysis of mentalizing impairments in adults with schizophrenia and autism spectrum disorder. Schizophrenia Bulletin, 40, 602–616.CrossRefGoogle ScholarPubMed
Cortés-García, L., Akça, Ö.F., Wall, K., & Sharp, C. (2021). Exploring mentalizing in adolescents with anorexia nervosa and borderline personality disorder: A comparative study of psychiatric inpatients and healthy controls. Scandinavian Journal of Child and Adolescent Psychiatry and Psychology. 9, 16–26.CrossRefGoogle ScholarPubMed
Duque-Alarcón, X., Alcalá-Lozano, R., González-Olvera, J. J., Garza-Villarreal, E. A., & Pellicer, F. (2019). Effects of childhood maltreatment on social cognition and brain functional connectivity in borderline personality disorder patients. Frontiers in Psychiatry, 10, 156.CrossRefGoogle ScholarPubMed
Dziobek, I., Fleck, S., Kalbe, E., Rogers, K., Hassenstab, J., Brand, M., … Convit, A. (2006). Introducing MASC: A movie for the assessment of social cognition. Journal of Autism and Developmental Disorders, 36, 623–636.CrossRefGoogle ScholarPubMed
Fertuck, E. A., Jekal, A., Song, I., Wyman, B., Morris, M. C., Wilson, S. T., … Stanley, B. (2009). Enhanced ‘Reading the Mind in the Eyes’ in borderline personality disorder compared to healthy controls. Psychological Medicine, 39, 1979–1988.CrossRefGoogle ScholarPubMed
Fonagy, P. (1989). On tolerating mental states: Theory of mind in borderline personality. Bulletin of the Anna Freud Centre, 12, 91–115.Google Scholar
Fonagy, P. (1991). Thinking about thinking: Some clinical and theoretical considerations in the treatment of a borderline patient. International Journal of Psycho-Analysis, 72, 1–18.Google ScholarPubMed
Fonagy, P., Luyten, P., Moulton-Perkins, A., Lee, Y. W., Warren, F., Howard, S., … Lowyck, B. (2016). Development and validation of a self-report measure of mentalizing: The Reflective Functioning Questionnaire. PLoS One, 11, e0158678.CrossRefGoogle ScholarPubMed
Frick, C., Lang, S., Kotchoubey, B., Sieswerda, S., Dinu-Biringer, R., Berger, M., … Barnow, S. (2012). Hypersensitivity in borderline personality disorder during mindreading. PLoS One, 7, e41650.CrossRefGoogle ScholarPubMed
Ghiassi, V., Dimaggio, G., & Brune, M. (2010). Dysfunctions in understanding other minds in borderline personality disorder: A study using cartoon picture stories. Psychotherapy Research, 20, 657–667.CrossRefGoogle ScholarPubMed
Harari, H., Shamay-Tsoory, S. G., Ravid, M., & Levkovitz, Y. (2010). Double dissociation between cognitive and affective empathy in borderline personality disorder. Psychiatry Research, 175, 277–279.CrossRefGoogle ScholarPubMed
Hausberg, M. C., Schulz, H., Piegler, T., Happach, C. G., Klöpper, M., Brütt, A. L. S., … Andreas, S. (2012). Is a self-rated instrument appropriate to assess mentalization inpatients with mental disorders? Development and first validation of the mentalization questionnaire (MZQ). Psychotherapy Research, 22, 699–709.CrossRefGoogle Scholar
Hill, J., Pilkonis, P., Morse, J., Feske, U., Reynolds, S., Hope, H., … Broyden, N. (2008). Social domain dysfunction and disorganization in borderline personality disorder. Psychological Medicine, 38, 135–146.CrossRefGoogle ScholarPubMed
Hillmann, K., Neukel, C., Krauch, M., Spohn, A., Schnell, K., Herpertz, S.C., & Bertsch, K. (2020). Cognitive and Affective Theory of Mind in Female Patients With Borderline Personality Disorder. Journal of Personality Disorders. 1–19. doi: 10.1521/pedi_2020_34_490Google ScholarPubMed
Kılıç, F., Demirdaş, A., Işık, Ü., Akkuş, M., Atay, İ.M., & Kuzugüdenlioğlu, D. (2020). Empathy, Alexithymia, and Theory of Mind in Borderline Personality Disorder. Journal of Nervous Mental Disease, 208, 736–741.CrossRefGoogle ScholarPubMed
Lecours, S., & Bouchard, M. A. (1997). Dimensions of mentalisation: Outlining levels of psychic transformation. The International Journal of Psychoanalysis, 78, 855–875.Google ScholarPubMed
Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M. M., & Bohus, M. (2004). Borderline personality disorder. Lancet (London, England), 364, 453–461.CrossRefGoogle ScholarPubMed
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.Google Scholar
McCallum, M., & Piper, W. E. (1996). Psychological mindedness. Psychiatry, 59, 48–64.CrossRefGoogle ScholarPubMed
Mier, D., Lis, S., Esslinger, C., Sauer, C., Hagenhoff, M., Ulferts, J., … Kirsch, P. (2013). Neuronal correlates of social cognition in borderline personality disorder. Social Cognitive and Affective Neuroscience, 8, 531–537.CrossRefGoogle ScholarPubMed
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. BMJ, 339, b2535.CrossRefGoogle ScholarPubMed
Monsen, J. T., Eilertsen, D. E., Melgård, T., & Odegård, P. (1996). Affects and affect consciousness : Initial experiences with the assessment of affect integration. The Journal of Psychotherapy Practice and Research, 5, 238–249.Google ScholarPubMed
Morandotti, N., Brondino, N., Merelli, A., Boldrini, A., De Vidovich, G. Z., Ricciardo, S., … Luyten, P. (2018). The Italian version of the Reflective Functioning Questionnaire: Validity data for adults and its association with severity of borderline personality disorder. PLoS One, 13, e0206433.CrossRefGoogle ScholarPubMed
Németh, N., Mátrai, P., Hegyi, P., Czéh, B., Czopf, L., Hussain, A., … Simon, M. (2018). Theory of mind disturbances in borderline personality disorder: A meta-analysis. Psychiatry Research, 270, 143–153.CrossRefGoogle ScholarPubMed
Németh, N., Péterfalvi, Á., Czéh, B., Tényi, T., & Simon, M. (2020). Examining the Relationship Between Executive Functions and Mentalizing Abilities of Patients With Borderline Personality Disorder. Frontiers in Psychology, 11, 1583. doi: 10.3389/fpsyg.2020.01583CrossRefGoogle ScholarPubMed
Normann-Eide, E., Antonsen, B. T., Kvarstein, E. H., Pedersen, G., Vaskinn, A., & Wilberg, T. (2019). Are impairments in theory of mind specific to borderline personality disorder? Journal of Personality Disorders, 20, 1–15.Google Scholar
Ortega-Díaz, E., García-Campos, J., Moya-Martínez, A., Ramírez-Cremades, C., Rico- Gomis, J.M., Cuesta-Moreno, C,……,Rodríguez-Marín, J. (2021). Theory of Mind in Borderline Personality Disorder: A Possible Endophenotypic Factor? International Journal of Environment Research Public Health, 18, 3193. doi: 10.3390/ijerph18063193.CrossRefGoogle ScholarPubMed
Ower, N. (2014). Effects of oxytocin on social cognition and empathy in women with borderline personality disorder. University of Freiburg (Thesis).Google Scholar
Perroud, N., Badoud, D., Weibel, S., Nicastro, R., Hasler, R., Küng, A. L., … Debbané, M. (2017). Mentalization in adults with attention deficit hyperactivity disorder: Comparison with controls and patients with borderline personality disorder. Psychiatry Research, 256, 334–341.CrossRefGoogle ScholarPubMed
Petersen, R., Brakoulias, V., & Langdon, R. (2016). An experimental investigation of mentalization ability in borderline personality disorder. Comprehensive Psychiatry, 64, 12–21.CrossRefGoogle ScholarPubMed
Pluta, A., Kulesza, M., Grzegorzewski, P., & Kucharska, K. (2018). Assessing advanced theory of mind and alexithymia in patients suffering from enduring borderline personality disorder. Psychiatry Research, 261, 436–441.CrossRefGoogle ScholarPubMed
Popolo, R., MacBeth, A., Canfora, F., Rebecchi, D., Toselli, C., Salvatore, G., & Dimaggio, G. (2019). Metacognitive Interpersonal Therapy in group (MIT-G) for young adults with personality disorders: A pilot randomized controlled trial. Psychology and Psychotherapy, 92, 342–358.CrossRefGoogle ScholarPubMed
Preissler, S., Dziobek, I., Ritter, K., Heekeren, H. R., & Roepke, S. (2010). Social cognition in borderline personality disorder: Evidence for disturbed recognition of the emotions, thoughts, and intentions of others. Frontiers in Behavioral Neuroscience, 4, 182.CrossRefGoogle ScholarPubMed
Premack, D., & Woodruff, G. (1978). Does the chimpanzee have a ‘theory of mind’? Behavioral and Brain Sciences, 4, 515–526.CrossRefGoogle Scholar
Quek, J., Melvin, G. A., Bennett, C., Gordon, M. S., Saeedi, N., & Newman, L. K. (2019). Mentalization in adolescents with borderline personality disorder: A comparison with healthy controls. Journal of Personality Disorders, 33, 145–163.CrossRefGoogle ScholarPubMed
Richman, M.J., & Unoka, Z. (2015). Mental state decoding impairment in major depression and borderline personality disorder: meta-analysis. British Journal of Psychiatry, 207, 483–489.CrossRefGoogle ScholarPubMed
Ritter, K., Dziobek, I., Preissler, S., Rüter, A., Vater, A., Fydrich, T., … Roepke, S. (2011). Lack of empathy in patients with narcissistic personality disorder. Psychiatry Research, 187, 241–247.CrossRefGoogle ScholarPubMed
Sabbagh, M. A. (2004). Understanding orbitofrontal contributions to theory-of-mind reasoning: Implications for autism. Brain and Cognition, 55, 209–219.CrossRefGoogle ScholarPubMed
Sabbagh, M. A., Moulson, M. C., & Harkness, K. L. (2004). Neural correlates of mental state decoding in human adults: An event-related potential study. Journal of Cognitive Neuroscience, 16, 415–426.CrossRefGoogle ScholarPubMed
Sacchetti, S., Robinson, P., Bogaardt, A., Clare, A., Ouellet-Courtois, C., Luyten, P.,…….., Fonagy, P. (2019). Reduced mentalizing in patients with bulimia nervosa and features of borderline personality disorder: A case-control study. BMC Psychiatry, 19, 134. doi: 10.1186/s12888-019-2112-9CrossRefGoogle ScholarPubMed
Savla, G. N., Vella, L., Armstrong, C. C., Penn, D. L., & Twamley, E. W. (2013). Deficits in domains of social cognition in schizophrenia: A meta-analysis of the empirical evidence. Schizophrenia Bulletin, 39, 979–992.CrossRefGoogle ScholarPubMed
Schilling, L., Wingenfeld, K., Löwe, B., Moritz, S., Terfehr, K., Köther, U., & Spitzer, C. (2012). Normal mind-reading capacity but higher response confidence in borderline personality disorder patients. Psychiatry and Clinical Neurosciences, 66, 322–327.CrossRefGoogle ScholarPubMed
Semerari, A., Carcione, A., Dimaggio, G., Nicoló, G., Pedone, R., & Procacci, M. (2005). Metarepresentative functions in borderline personality disorder. Journal of Personality Disorders, 19(6), 690–710.CrossRefGoogle ScholarPubMed
Sharp, C., & Fonagy, P. (2008). Social cognition and attachment-related disorders. In Sharp, C., Fonagy, P., & Goodyer, I. M. (Eds.), Social cognition and developmental psychopathology (pp. 271–304). Oxford, England: Oxford University Press.CrossRefGoogle Scholar
Sharp, C., Williams, L., Ha, C., Baumgardner, J., Michonski, J., Seals, R., ……. Fonagy, P. (2009). The development of a mentalization-based outcomes and research protocol for an adolescent in-patient unit. The Bulletin of the Menninger Clinic, 73, 311–338.CrossRefGoogle Scholar
Sharp, C., Ha, C., Carbone, C., Kim, S., Perry, K., Williams, L., & Fonagy, P. (2013). Hypermentalizing in adolescent inpatients: Treatment effects and association with borderline traits. Journal of Personality Disorders, 27, 3–18.CrossRefGoogle ScholarPubMed
Sharp, C., Pane, H., Ha, C., Venta, A., Patel, A. B., Sturek, J., & Fonagy, P. (2011). Theory of mind and emotion regulation difficulties in adolescents with borderline traits. Journal of the American Academy of Child & Adolescent Psychiatry, 50, 563–573.CrossRefGoogle ScholarPubMed
Sharp, C., & Vanwoerden, S. (2015). Hypermentalizing in borderline personality disorder: A model and data. Journal of Infant, Child, and Adolescent Psychotherapy, 14, 33–45.CrossRefGoogle Scholar
Somma, A., Ferrara, M., Terrinoni, A., Frau, C., Ardizzone, I., Sharp, C., & Fossati, A. (2019). Hypermentalizing as a marker of borderline personality disorder in Italian adolescents: A cross-cultural replication of Sharp and colleagues' (2011) findings. Borderline Personality Disorder and Emotion Dysregulation, 6, 5.CrossRefGoogle ScholarPubMed
Stone, V. E., Baron-Cohen, S., & Knight, R. T. (1998). Frontal lobe contributions to theory of mind. Journal of Cognitive Neuroscience, 10, 640–656.CrossRefGoogle ScholarPubMed
Unoka, Z. S., Fogd, D., Seres, I., Kéri, S., & Csukly, G. (2015). Early maladaptive schema-related impairment and co-occurring current major depressive episode-related enhancement of mental state decoding ability in borderline personality disorder. Journal of Personality Disorders, 29, 145–162.CrossRefGoogle ScholarPubMed
Van Heel, M., Luyten, P., De Meulemeester, C., Vanwalleghem, D., Vermote, R., & Lowyck, B. (2019). Mentalizing based on external features in borderline personality disorder compared with healthy controls: The role of attachment dimensions and childhood trauma. Journal of Personality Disorders, 28, 1–15.Google Scholar
Viechtbauer, W. (2010). “Conducting meta-analyses in R with the metafor package.” Journal of Statistical Software, 36, 1–48.CrossRefGoogle Scholar
Wingenfeld, K., Kuehl, L. K., Janke, K., Hinkelmann, K., Dziobek, I., Fleischer, J., … Roepke, S. (2014). Enhanced emotional empathy after mineralocorticoid receptor stimulation in women with borderline personality disorder and healthy women. Neuropsychopharmacology, 39, 1799–1804.CrossRefGoogle ScholarPubMed
Winsper, C., Marwaha, S., Lereya, S. T., Thompson, A., Eyden, J., & Singh, S. P. (2015). Clinical and psychosocial outcomes of borderline personality disorder in childhood and adolescence: A systematic review. Psychological Medicine, 45, 2237–2251.CrossRefGoogle ScholarPubMed
Yeh, Z., Lin, Y., Liu, S., & Fang, C. (2017). Social awareness and its relationship with emotion recognition and theory of mind in patients with borderline personality disorder. Journal of Social and Clinical Psychology, 36, 22–40.CrossRefGoogle Scholar
Zabihzadeh, A., Maleki, G., Richman, M. J., Hatami, A., Alimardani, Z., & Heidari, M. (2017). Affective and cognitive theory of mind in borderline personality disorder: The role of comorbid depression. Psychiatry Research, 257, 144–149.CrossRefGoogle ScholarPubMed
Zegarra-Valdivia, , & Chino, B. (2019). Social cognition and executive function in borderline personality disorder: Evidence of altered cognitive processes. Salud Mental, 42, 33–41.CrossRefGoogle Scholar
Supplementary material: Image

Bora supplementary material

Figure S1

Download Bora supplementary material(Image)
Image 46 KB