INTRODUCTION
Borderline personality disorder (BPD) is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, affects, and behavior, as well as by marked impulsivity.1 BPD is a chronic and debilitating mental disorder, whose estimated median prevalence is 1.6%.1 It is associated with frequent episodes of self-injury and with high mortality, and has the highest degree of suicidality among personality disorders.1–3
As postulated by Gunderson,4 affective instability, impulsivity, and disturbed relationships represent the three core symptom dimensions of BPD. Crucially, disturbed relationships have been proposed as the best discriminator for the diagnosis of BPD and are increasingly recognized as being essential to understand the impairment and distress associated with the disorder.4
Empathy and Related Concepts
Empathy is commonly used as a lay term indicating the ability to understand “others”—the capacity to “put yourself in someone else’s shoes.” However, from the psychological, developmental, and cognitive neuroscience points of view, the concept of empathy is complex5,6 and embodies different dimensions. The most well-known dimensions of empathy are the following: cognitive and emotional. In addition, motor empathy has been proposed as a distinct dimension representing the imitation of motor responses (e.g., facial expressions, vocalizations, postures, and movements) of “others.”5 This dimension has been incorporated in models underlying empathy across a wide range of animal species.7,8
Emotion recognition refers to the identification of emotions from expressions (e.g., facial). The identification of emotions subsequently enables one to infer emotional states. Human faces are a rich source of information regarding subjective emotional states and social communication.9 This information is a prerequisite for (emotional) empathy.
Emotional empathy is conceptualized as the ability to respond to emotional states of “others”10 in a sympathetic manner (i.e., by experiencing them vicariously). Such a state-matching reaction has been related to the mirror neuron system.11,12 This system corresponds to a set of specialized neurons, primarily located in the premotor cortex, that are believed to be engaged in “mirroring” the behavior and actions of others.12 The hypothesis that emotional empathy could be related to this system is supported by functional neuroimaging data showing decreased activation at the right pars opercularis of the inferior frontal gyrus—a part of the mirror neuron system—in children with reduced empathy (e.g., as in autism spectrum disorder), during both imitation and observation of facial emotional expressions.13
It is increasingly recognized that emotional and cognitive empathy are interconnected.8Cognitive empathy is the ability to take the perspective of “others” without necessarily being sympathetic or experiencing it vicariously.5 According to Blair,5 cognitive empathy is, in effect, the theory of mind (ToM).
ToM refers to the ability of attributing significance to mental states (e.g., beliefs, desires, feelings, intentions, needs, thoughts, and reasons) of “self and others” in order to understand, explain, and predict behaviors.14,15 The concept of affective ToM has also been proposed to capture the importance of emotion (and emotion recognition) in attributing significance to mental states. Therefore, emotion recognition can help to differentiate affective ToM from the purely cognitive characteristics of ToM.16,17
Another concept closely related to ToM is mentalization (i.e., mentalizing). Mentalizing corresponds to the ability to understand and interpret the mental states of “oneself and others.”18,19 Although the term mentalizing does not refer to quite the same phenomenon as ToM20—mentalizing mostly refers to an affective and self-oriented dimension, whereas ToM mostly implies cognitive understanding and attribution of significance to mental states of “others”—the terms are often used interchangeably.21
Social cognition mostly includes information processing about “others, the self, and the norms of the social world.”22 It is also a broad concept encompassing processes such as emotion recognition, empathy, ToM, and mentalizing, and contributes to the ability of an individual to understand and effectively respond to the perspectives of “others,” enabling humans to establish and maintain interpersonal relationships.23
Finally, emotional intelligence includes perceiving, assimilating, understanding, and managing emotions.24,25
In summary, empathy, ToM, mentalizing, social cognition,26 and emotional intelligence are closely related concepts. Although they are all different from one another, and authors have conflicting and often confusing views about them, it is widely believed that impairment of the underlying mental processes occurs in several psychiatric disorders.
Dysfunction of Empathy and Related Processes in Borderline Personality Disorder
Dysfunction of empathy and related processes in patients with BPD has been widely suggested. Fonagy27 first described the inability of perceiving mental states in BPD as a probable defense mechanism to early trauma, physical abuse (e.g., sexual), and dysfunctional family relationships. Using a questionnaire aimed at assessing adult representation of attachment by means of memories from their childhood—the Adult Attachment Interview developed by Carol George, Nancy Kaplan, and Mary Main in the mid-1980s—Fonagy and colleagues28 confirmed the existence of deficits in the awareness of mental states contributing to the pattern of interpersonal dysfunction in BPD. Likewise, deficits related to inaccurate attribution and representation of behaviors are believed to be characteristic of patients with BPD.29 Furthermore, mentalization-based therapy was found to be effective in patients with BPD.30
Nevertheless, the results are inconsistent regarding the role of empathy and related processes as a source of disturbed interpersonal relationships in BPD. A key example here is the empathic paradox that occurs in patients with BPD. The empathic paradox, or borderline empathy paradox, is characterized by enhanced empathy, in spite of impaired interpersonal functioning.26,31,32 In other words, it corresponds to a peculiar ability of certain patients with BPD to recognize even subtle emotional states of others, without the corresponding ability to facilitate interpersonal relationships.
The purpose of this review is to assess differences in empathy and related processes (i.e., ToM, mentalizing, social cognition, and emotional intelligence) between patients with BPD and healthy subjects.
METHODS
Literature Search and Selection Criteria
The PubMed database was searched for articles that were published in English and used the term borderline personality disorder and any of the following: empathy, theory of mind, mentalizing, mentalising, mentalization, mentalisation, social cognition, or emotional intelligence. In order to include further peer-reviewed articles of interest in the field of psychology, an additional search—using the same terms—was performed on the PsycINFO database. The closing date for the searches was 31 December 2019.
All publications were scrutinized to confirm whether they were substantively related to the purpose of the current review. We selected original research articles involving adult patients with the main diagnosis of BPD using criteria from the third revised,33 fourth revised,34 and fifth1 editions of the Diagnostic and Statistical Manual of Mental Disorders. We also used criteria from the tenth revised edition of the International Classification of Diseases35 for the “emotionally unstable personality disorder, borderline type.” Mandatory inclusion criteria were the use of measures of empathy or related processes and also the existence of a group of healthy control subjects in the studies. Given that patterns of abnormal brain functioning may underlie empathic dysfunction in patients with BPD, studies using functional neuroimaging in this setting were also included.
Review articles (e.g., including those providing meta-analytic results), commentaries, and editorials that exclusively addressed the theoretical background of BPD were not included. Nevertheless, publications addressing empathy and related concepts in BPD were surveyed for bibliographic references indicating original research articles of interest not found in the PubMed and PsycINFO searches.
Results of studies based on emotion-recognition tasks without an explicit mention of empathy or related processes were excluded, as were studies on borderline personality symptoms, traits/features, or attachment style, and studies specifically including adolescents in their samples. Furthermore, studies about biological mediators, type and effects of therapies (e.g., mentalization-based therapy), and pharmacological modulation in BPD were excluded.
Supplemental Figure 1 presents a flow diagram showing how the included studies were selected (available at https://links.lww.com/HRP/A125).
Measures of Empathy and Related Processes
A major challenge in assessing empathy and related processes is the availability of tests developed that take into account real-life conditions.36 Moreover, applied tests are expected to be reliable enough to “represent” mental processes underlying the theoretical concepts discussed above. We report results of studies using well-known, published, or “ecologically valid” tests for assessing empathy or related processes in BPD. Specifically, the ecological validity of a test refers to how well it mirrors real-life conditions and, therefore, how clinically useful the test might be.
Tests used in more than one of the included studies for this review are described below under separate subsections, in chronological order of the earliest publication. In a subsequent subsection, the test used to assess emotional intelligence is also described. Tests less often used (i.e., only used in a single included study) are described under a common subsection entitled “Other Measures.”
Interpersonal Reactivity Index
The Interpersonal Reactivity Index (IRI)10 is a self-report questionnaire aimed at evaluating empathy in a two-dimensional way (i.e., cognitive and emotional). The IRI consists of four 7-item subscales: two cognitive subscales (perspective taking [PT] and fantasy [FS]) and two emotional subscales (empathic concern [EC] and personal distress [PD]). The score of each subscale corresponds to the results of a 5-point Likert scale (possible range of scores per item: 0–4 or 1–5).
Happé’s advanced ToM test
There are two different implementations of Happé’s advanced ToM test, also known as the “strange stories” task,37–39 to assess ToM capacities in patients with BPD.
Arntz and colleagues40 used the most complete implementation of this test. Their version consists of a mental and a physical subtest, each comprising eight stories on small illustrations. The mental subtest presents two stories involving double bluffs, mistakes, persuasion, and white lies (i.e., harmless or trivial lies, to avoid hurting the feelings of others). This subtest evaluates ToM by requiring inferences concerning the thoughts, feelings, and intentions of the characters. The physical subtest includes stories requiring the inference of physical causation, irrespective of the characters’ mental states. Incorrect answers are scored 0; implicit or partly correct answers are scored 1; and explicit, complete answers are scored 2. The maximum possible score is 16 per subtest. An average score for each subtest can also be calculated.40
Yeh and colleagues41 used a simpler and less well-characterized implementation of this test. This implementation includes only five stories, and the maximum possible score is 10.
Faux Pas detection test
The Faux Pas task42,43 is believed to assess both cognitive and affective ToM capacities. Questions are made about a set of written stories, for the detection of a faux pas, which literally means a “misstep” and is actually defined by Baron-Cohen and colleagues43(p 408) as a sort of communication “without considering if it is something that the listener might not want to hear or know, and which typically has negative consequences that the speaker never intended.” It involves the inference of mental states and emotions of the characters in the stories. The various implementations of this test differ mainly in the number and type of questions used, and subsequently regarding the possible range of scores. Usually, this test comprises a set of 20 stories, but one implementation uses only 10.41
Reading the Mind in the Eyes Test
The Reading the Mind in the Eyes Test (RMET), revised version,44 assesses ToM capacities. This test relies on the observation of 36 black-and-white photographs of the eye region of different human faces. Participants are asked to choose, from four available mental-state descriptors (e.g., annoyance, amusement, bewilderment, reflectiveness), the descriptor that best matches the mental state of the person whose eyes are represented in each photograph, without any specific time constraint. If necessary, a glossary containing the meaning of the mental-state descriptors can be presented during assessment. The total score is the number of correctly identified mental-state attributions (possible range of scores: 0–36). To ascertain mental-state decoding on the basis of emotional valence, Harkness and colleagues45 and Scott and colleagues46 differentiated the stimuli into positive, neutral, and negative, each ranked by the observer on a 7-point Likert scale. To evaluate the confidence rating of responses on the RMET, Schilling and colleagues47 asked subjects to rate how confident they were about their responses.
Additional implementations of the RMET have been proposed. Preißler and colleagues36 used a total number of 40 photographs instead of 36. Frick and colleagues48 presented the possible choices of mental state attributions after each photograph’s display, as well as time limits for such display and the mental-state decoding. The latter implementation is especially well suited for functional magnetic resonance imaging (fMRI) studies.
Empathy Quotient
The Empathy Quotient (EQ)49,50 is a self-report questionnaire comprising 60 items, 40 of which aimed to assess empathy using a 4-point Likert scale: definitely agree, slightly agree, slightly disagree, and definitely disagree. A non-empathetic response is rated 0, and an empathetic response is rated 1 or 2, depending on the strength of the response (resulting in total scores from 0 to 80).
Movie for the Assessment of Social Cognition
The Movie for the Assessment of Social Cognition (MASC)51 questionnaire relies on a nearly 15-minute video showing interactions between four characters gathering for a dinner party. Dominant topics of the interactions between characters involve dating and friendship issues. The video is paused during its presentation so that questions about the characters’ feelings, thoughts, and intentions (i.e., requiring social cognition) can be answered by selecting the most accurate response among the four available options. The three types of error (for each question) are considered to correspond to overmentalizing, reduced ToM, and no ToM. Reduced or no ToM corresponds to undermentalizing errors. The MASC has 15 items “challenging the interpretation of emotions,” 14 items “challenging the interpretation of intentions,” 4 items to “measure thoughts,” and 4 control questions. Correct responses are scored 1, and incorrect responses are scored 0. An overall score, as well as different subscale scores, can be calculated. Andreou and colleagues52 evaluated the confidence rating of responses on the MASC.
Multifaceted Empathy Test
The Multifaceted Empathy Test (MET)53 is a computer-assisted method comprising 23 pairs of picture stimuli showing people in emotionally charged conditions. It allows assessment of both cognitive and emotional empathy. Cognitive empathy is assessed by inferring the mental states of individuals displayed in photographs (one correct attribution out of four possible mental-state descriptors). Emotional empathy is evaluated by rating the emotional reactions of subjects in response to the pictures; a 9-point Likert empathic-concern subscale is used.
Dziobek and colleagues54 proposed an adaptation of the MET for fMRI, using a series of 80 less ambiguous pictures and a two-option answer for both the cognitive- and emotional-empathy subscales. Ritter and colleagues55 evaluated emotional empathy not only using the empathic-concern subscale but also scoring emotional contagion (i.e., mirroring emotions) with a 0–9 point visual analogue scale. Finally, Wingenfeld and colleagues56,57 proposed a modified version of the MET using 30 picture stimuli.
Reflective Functioning Questionnaire
The Reflective Functioning Questionnaire (RFQ)58 is a mentalizing self-report measure with responses to specific items scored on a 6- to 7-point Likert scale, rescored from 0–2 or 0–3 both for a subscale of certainty (RFQ_C) and a subscale of uncertainty (RFQ_U) about mental states of self and others. The RFQ provides measures of empathy, mindfulness, and perspective taking, both associated with self- and clinician-reported measures of borderline personality features.58
Mayer-Salovey-Caruso Emotional Intelligence Test
The Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT)25 is a performance-based measure to assess the following four branches (skills) of emotional intelligence: perceiving emotions, assimilating or using emotions to facilitate thought, understanding emotions, and regulating or managing emotions. Each of the four skills is measured with two tasks. Different scoring methods are implemented for each task.25
Other measures
The Picture Sequencing Task consists of 11 stories, each in the form of a four-card picture set,59 and an additional story designed to detect a false belief.60 A short version of this test or the False-Belief Picture Sequencing Task uses 10 stories in patients with BPD, 4 of which assess simple cognitive understanding of false beliefs (involving cognitive ToM).61
The Mental State Attribution Tasks (MSAT)62 assess ToM capacities. The MSAT total (MSAT-T) score corresponds to the sum of the MSAT event sequencing (MSAT-S) plus the MSAT questionnaire (MSAT-Q) subscores. The MSAT-S comprises six cartoon picture stories, each represented by four cards, indicating three specific types of social interaction: a cooperation between two subjects, one subject tricking another, and two subjects cooperating to deceive a third one. It tests the ability of the participants to order cards in a logical sequence of events, and the corresponding subscore is based upon a rating method proposed by Langdon and colleagues.59 The maximum possible subscore for the MSAT-S is 36. The MSAT-Q comprises 23 questions to test the ability of participants to recognize the characters’ mental states (e.g., cooperation, deception, and beliefs). Each correct answer on the MSAT-Q corresponds to a subscore of 1. Therefore, the possible range of scores for the MSAT-T is 0–59. According to Ghiassi and colleagues,63 the MSAT-Q subscore is considered to be “the most interesting component” of the MSAT to assess ToM capacities in patients with BPD.
The Theory of Mind Assessment Scale64,65 consists of a semistructured interview assessing cognitive and affective ToM capacities. Its current implementation uses 37 open-ended questions divided into four scales by means of which participants are prompted to express understanding of their mental states and those of others.
The Joke-Appreciation66 and Nonverbal ToM41 tasks correspond to novel measures of ToM capacities partly based on Happé’s advanced ToM test. Both address implicit or nonverbal ToM and were included as valid measures for this review. Likewise, the Questionnaire of Cognitive and Affective Empathy67 is a relatively novel instrument for assessing empathy partly based on the Interpersonal Reactivity Index and Empathy Quotient self-report questionnaires.
Self-report mentalizing abilities can be assessed using the Mentalization Questionnaire (MZQ)68 or the Mentalization Scale (MentS).69 Although none of these measures is clearly related to other well-known tests, their reliability was reported to be satisfactory.68,69
Finally, Niedtfeld70 used an approach to assess emotional empathy in BPD based on the relative contribution of facial expressions, prosody, and speech content. This approach was previously used in healthy subjects and in patients with psychiatric conditions other than BPD.71
Analysis
All studies were analyzed as to whether they reported decreased, similar, or increased levels of empathy or related processes in patients with BPD relative to healthy control subjects, according to the statistical thresholds used in the corresponding publications (Tables 1–10).
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Table 1: Samples and Main Findings of Studies Using the Interpersonal Reactivity Index as a Measure of Empathy in BPD
Table 2: Samples and Main Findings of Studies Using Happé’s Advanced ToM Test as a Measure of ToM Capacities in BPD
Table 3: Samples and Main Findings of Studies Using the Faux Pas Detection Test as a Measure of ToM Capacities in BPD
Table 4: Samples and Main Findings of Studies Using the Reading the Mind in the Eye Test as a Measure of ToM Capacities in BPD
Table 5: Samples and Main Findings of Studies Using the Empathy Quotient as a Measure of Empathy in BPD
Table 6: Samples and Main Findings of Studies Using the Movie for the Assessment of Social Cognition as a Measure of ToM Capacities in BPD
Table 7: Samples and Main Findings of Studies Using the Multifaceted Empathy Test as a Measure of Empathy in BPD
Table 8: Samples and Main Findings of Studies Using the Reflective Functioning Questionnaire as a Measure of Mentalizing in BPD
Table 9: Samples and Main Findings of Studies Using the Mayer-Salovey-Caruso Emotional Intelligence Test in BPD
Table 10: Samples and Main Findings of Studies Using Other Measures of Empathy and Related Processes in BPD
RESULTS
Forty-five studies, published between 2000 and 2019, were included in this review.17,36,40,41,47,48,52,54–57,61,63,69,70,72–101 Thirteen (28.9%) of the 45 studies comprised samples of patients with psychiatric conditions other than BPD,40,41,52,55,72,74,77,81,82,87,91,97,100 including other personality disorders, major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), schizophrenia, substance abuse disorder, and anorexia nervosa (Tables 1–4 and 6–10). All but two studies47,82 reported sex distributions for patients with the diagnosis of BDP. The female-to-male ratio of patients included in studies reporting sex distribution was 8:1.
Interpersonal Reactivity Index
Eleven (24.4%) of the 45 studies included in this review used the IRI as a measure of empathy (Table 1).17,54,55,61,72,76,79,83–86
Interpersonal Reactivity Index cognitive subscales
Seven studies using the perspective-taking subscale of the IRI found a significant reduction of the corresponding scores in patients with BPD relative to healthy control subjects.55,61,76,83–86 Three studies did not find significant differences of PT scores between groups.54,72,79
No study found a significant difference of fantasy scores between patients with BPD and healthy control subjects.54,61,72,76,79,83–86
Harari and colleagues17 and Martin and colleagues86 calculated the sum of scores from both cognitive subscales of the IRI (i.e., the PT + FS score). Both studies revealed an overall deficit of cognitive empathy in patients with BPD.17,86
Interpersonal Reactivity Index emotional subscales
Eight studies using the personal-distress subscale of the IRI found enhanced distress in patients with BPD.54,61,72,76,79,83,84,86 One study did not find a significant difference of PD scores between patients and controls.85
Two studies reported impaired,55,85 and one study reported enhanced, empathic concern in patients with BPD,72 but the vast majority of studies did not find significant differences of EC scores between patients and controls.54,61,76,79,83,84,86
In parallel with their calculations regarding the cognitive subscales, Harari and colleagues17 and Martin and colleagues86 also calculated the sum of scores from both emotional subscales of the IRI (i.e., the EC + PD score). Martin and colleagues86 reported enhanced emotional empathy in patients, whereas Harari and colleagues17 did not.
Happé’s Advanced ToM Test
Two (4.4%) of the 45 studies included in this review used Happé’s advanced ToM test (Table 2).40,41 None of them found a significant difference between patients with BPD and healthy control subjects in terms of ToM capacities as assessed by this test.40,41
Faux Pas Detection Test
Six (13.3%) of the 45 studies included in this review used the Faux Pas detection test as a measure of ToM capacities (Table 3).17,41,61,78,88,94 Five of these studies found significant deficits of ToM in patients with BPD.17,61,78,88,94 One study did not find a significant difference between patients and controls in recognizing faux pas.41
Two of these six studies independently analyzed the cognitive and affective domains of ToM.17,78 Both studies found deficits of cognitive ToM in patients with BPD. Baez and colleagues78 also found deficits of affective ToM in patients, whereas Harari and colleagues17 did not.
Reading the Mind in the Eyes Test
Thirteen (28.9%) of the 45 studies included in this review used the RMET to assess ToM capacities (Table 4).36,47,48,61,73,78,80,88,89,91,98,99,101
Four studies reported lower,80,89,98,101 and three studies reported higher,48,73,88 RMET total scores in patients with BPD relative to healthy control subjects, but six studies did not find a significant difference between patients and controls in the RMET total score.36,47,61,78,91,99 Schilling and colleagues47 reported a pattern of high confidence ratings for correct and incorrect answers in patients.
Nine studies assessed emotional valences on the RMET.47,48,61,73,80,88,89,91,98Table 4 presents detailed information regarding the diversity of results from these studies.
Empathy Quotient
Two (4.4%) of the 45 studies included in this review used the EQ as a measure of empathy (Table 5).79,96 Both studies found reduced EQ scores in patients with BPD relative to healthy control subjects.79,96
Movie for the Assessment of Social Cognition
Seven (15.6%) of the 45 studies included in this review used the MASC as a measure of ToM or mentalizing and social cognition (Table 6).36,52,55,56,81,97,99
Two studies found reduced MASC scores in patients with BPD relative to healthy control subjects.36,55 In particular, they found an average reduction of 4.6 points in the MASC total score, as well as an average reduction of 1.7 points in the score specifically measuring items “challenging the interpretation of intentions” in patients with BPD.36,55 With respect to items “challenging the interpretations of emotions” and regarding the capacity to “measure thoughts,” Preißler and colleagues36 found lower scores in patients with BPD relative to controls, whereas Ritter and colleagues55 did not find a significant difference between groups.
Although four studies did not find significant differences of MASC scores between patients with BPD and healthy control subjects,56,81,97,99 three studies revealed an increase of overmentalizing errors in patients.52,81,97 In addition, one study revealed “overconfidence in errors” as the major abnormality in BPD.52
Multifaceted Empathy Test
Four (8.9%) of the 45 studies included in this review used the MET as a measure of empathy (Table 7).54–57
On the MET cognitive subscale, Dziobek and colleagues54 found deficits of cognitive empathy in women with BPD, but no other study found a significant difference between patients with BPD and healthy control subjects on this subscale.55–57
On the MET emotional subscale, two studies found deficits of emotional empathy in patients with BPD.54,55 Specifically, these studies found an average reduction of 0.9 points in the “emphatic concern” subscale score of patients with BPD relative to healthy control subjects.54,55 One of these studies also found impaired “emotional contagion” in patients.55
Two studies by Wingenfeld and colleagues56,57 did not find significant differences of emotional empathy between women with BPD under usual conditions and healthy control women, but one of these studies reported deficits of emotional empathy in women with BPD under stress.57
Reflective Functioning Questionnaire
Three (6.7%) of the 45 studies included in this review used the RFQ as a measure of mentalizing (Table 8).87,90,93
Perroud and colleagues87 found higher RFQ_U and lower RFQ_C scores in patients with BPD relative to healthy control subjects. Likewise, Badoud and colleagues90 calculated the RFQ total score by subtracting the RFQ_C score from the RFQ_U score. The result was a negative value for the subtraction (−4.4) in patients with BPD, and a positive value (+7.5) in healthy controls.90
The main purpose of a study by Morandotti and colleagues93 was to differentiate patients with BPD from healthy subjects by using receiver operating characteristic curves. Their study found that the RFQ_U score was particularly useful for such a differentiation and also for predicting BPD severity.93
Mayer-Salovey-Caruso Emotional Intelligence Test
Six (13.3%) of the 45 studies included in this review used the MSCEIT as a measure of emotional intelligence (Table 9).74,75,77,82,96,100 Four of these studies found deficits of emotional intelligence in patients with BPD.74,77,82,100 Two studies did not find significant differences of emotional intelligence between patients and controls.75,96
Other Measures
Table 10 summarizes results of the eight studies (17.8%) using other measures of empathy and related processes.
The Questionnaire of Cognitive and Affective Empathy revealed decreased cognitive empathy, but similar levels of emotional empathy, in patients with BPD relative to healthy control subjects.92 Curiously, in women with BPD, Niedtfeld70 found enhanced emotional contagion secondary to nonverbally expressed emotions (i.e., ones just conveyed by emotionally charged facial expressions and prosody, but not by speech content) and lack of emotional empathy when both speech content and nonverbally expressed emotions were presented.70
The Joke-Appreciation and the Nonverbal ToM tasks revealed deficits of ToM in patients with BPD.41,61 Colle and colleagues95 also reported ToM deficits using the Theory of Mind Assessment Scale and found them to be more pronounced when mindreading tasks of patients required them to undertake an “allocentric” perspective—that is, the perspective of another individual. Likewise, the Mentalization Questionnaire and the Mentalization Scale revealed deficits of mentalizing abilities in BPD.69,89
The False-Belief Picture Sequencing Task and the Mental State Attribution Tasks did not reveal significant differences between patients with BPD and healthy control subjects in terms of ToM.61,63 Ghiassi and colleagues63 reported, however, that parental care during childhood influenced ToM capacities of patients with BPD as assessed by the MSAT; maternal rejection and punishment, taken together, were found to be a significant predictor of poor mentalizing in BPD.63
Summary of Results Across Studies
Thirty-six studies included in this review reported deficits of empathy (i.e., cognitive or emotional), ToM, mentalizing, social cognition, or emotional intelligence in patients with BPD.17,36,41,47,52,54,55,57,61,69,70,74,76–90,92–98,100,101
Eight studies reported enhanced emotional empathy in patients with BPD, mostly because of an increase in the PD subscale scores of the IRI.54,61,72,76,79,83,84,86 Curiously, three studies using the RMET also revealed enhanced ToM capacities in patients with BPD.48,73,88
Contradictory results between distinct tests for assessing empathy and related processes were reported in three studies.54,79,88 The study by Dziobek and colleagues54 showed deficits of both cognitive and emotional empathy on the MET but revealed enhanced emotional empathy on the basis of the PD subscale of the IRI. Matzke and colleagues79 reported deficits of empathy on the basis of the EQ but found enhanced emotional empathy on the basis of the PD subscale of the IRI. Finally, Zabihzadeh and colleagues88 found lack of ToM capacities in patients with BPD based on the Faux Pas detection test but found enhanced ToM capacities on the RMET.
Six studies showed no significant differences of empathy or related processes between patients with BPD and healthy control subjects.40,56,63,75,91,99 With respect to the tests employed in these studies, Arntz and colleagues40 used Happé’s advanced ToM test; Beblo and colleagues,75 the MSCEIT; Ghiassi and colleagues,63 the MSAT; Wingenfeld and colleagues,56 the MASC and the MET; Berenson and colleagues,91 the RMET; and Duque-Alarcón and colleagues,99 the RMET and the MASC.
Comorbidities
Eight (17.8%) of the 45 studies included in this review analyzed the possible effect of comorbid psychiatric conditions on dysfunction of empathy and related processes in BPD.36,73,80,87,88,91,94,96
Preißler and colleagues36 reported significantly lower MASC scores for items to “measure thoughts” in patients with BPD and comorbid posttraumatic stress disorder (PTSD) relative to patients without comorbid PTSD. In addition, this study found the following two significant predictors of poor social cognition: intrusive symptoms (a core feature of PTSD) and history of sexual trauma.36
Unoka and colleagues80 reported higher RMET total, neutral valence, and negative valence scores in patients with BPD and major depressive episode relative to patients without this comorbidity. Zabihzadeh and colleagues88 also reported higher RMET total and negative valence, but lower positive valence, scores in patients with BPD and comorbid MDD relative to patients without comorbid MDD. By using the Faux Pas detection test, this study found reduced ToM capacities in patients with BPD and comorbid MDD relative to patients without comorbid MDD.88
Finally, Perroud and colleagues87 found higher RFQ_U scores in patients with BPD and comorbid ADHD relative to patients without comorbid ADHD. No further significant contribution of comorbidities for the pattern of empathic dysfunction in BPD was reported.
Neuroimaging
Two (4.4%) of the 45 studies included in this review assessed empathy or related processes in the setting of blood oxygenation level–dependent (BOLD) fMRI.48,54
Using an adaptation of the MET for fMRI, Dziobek and colleagues54 found that patients with BPD showed less activation of the left superior temporal gyrus in a condition challenging cognitive empathy but found higher activation of the right insular cortex in a condition challenging emotional empathy.
Using the implementation of the RMET for fMRI, Frick and colleagues48 found activation of multiple brain regions both in patients with BPD and healthy control subjects. The authors highlighted a pattern of enhanced activation of the right amygdala during positive emotional valence stimuli and a pattern of enhanced activation of the left amygdala during negative emotional valence stimuli in patients with BPD.
DISCUSSION
Eighty percent of the studies included in this review reported deficits of empathy or related processes in patients with BPD.17,36,41,47,52,54,55,57,61,69,70,74,76–90,92–98,100,101 Moreover, enhanced emotional empathy in BPD was reported in eight studies, all of which revealed that patients had increased scores of distress on the IRI self-report questionnaire.54,61,72,76,79,83,84,86 Several studies found no significant differences between patients with BPD and healthy control subjects in terms of empathy or related processes,40,56,63,75,91,99 and some even found contradictory results between distinct tests.54,79,88 No study reported enhanced cognitive empathy, social cognition, or emotional intelligence in patients with BPD.
Clinical heterogeneity (i.e., differences in characteristics of patients) across samples partly explains the diversity of results reported by studies included in this review. Specifically, demographic factors (age, sex, and education), the severity of BPD symptoms, history of traumatic events, history of suicidal attempts, features leading to hospitalization, concurrent medication, and psychiatric comorbidities might have influenced the reported results. A key example here is the influence of childhood trauma and comorbid PTSD on the development of empathic dysfunction in BPD,36,102 which leads to a practical inability in determining where the aberrations in empathy and related processes originated. Statistical variance due to small sample sizes might also have contributed to the diversity of results.
The measures used to assess empathy and related processes can also explain part of the results, and some tests might even be unable to detect abnormalities. An example is perhaps the RMET,44 which—despite being the most frequently used test in studies included in this review36,47,48,61,73,78,80,88,89,91,98,99,101—was the test that most often did not detect differences between patients and controls,36,61,78,91,99 and the only one revealing enhanced ToM capacities in patients with BPD.48,73,88 Maybe the absence of stimuli resembling realistic social interactions on the RMET can explain the presumably inaccurate results.
The absence of realistic social interactions is also a common feature of performance-based tests using cartoons or illustrations to present stimuli, such as Happé’s advanced ToM test, the False-Belief Picture Sequencing Task, and the MSAT. None of these tests revealed significant differences between patients with BPD and healthy subjects in terms of ToM.
In addition, results based on the IRI, EQ, RFQ, and other self-report measures should be interpreted with caution because these tests are dependent on the participants’ ability to understand percepts, perspectives, and emotions—an ability potentially lacking in patients with mental disorders.
Alternatively, some of the applied measures might have disproportionately weighted different dimensions of empathy and related processes in patients with BPD. This can lead to somewhat discrepant results, such as those reported by Dziobek and colleagues,54 in which a decrease of cognitive and emotional empathy was shown using the MET, whereas enhanced emotional empathy was revealed using the PD subscale of the IRI. It is conceivable that the reason for such a discrepancy might be the absence of a specific measure of distress on the MET.
Lack of cognitive empathy, ToM, mentalizing, social cognition, or emotional intelligence was found to be a common feature among patients with BPD. This can explain a failure in their process of repairing disrupted social cooperation, which is a finding supported by neuroimaging data in the setting of an economic exchange game with healthy partners.103
The possible concomitance of reduced emotional empathy further diminishes the ability of patients with BPD to sustain social cooperation, but a most intriguing finding is the possible occurrence of the empathic paradox, or borderline empathy paradox, in these patients.31,32 This is a form of enhanced emotional empathy enabling access to the emotions of others, which are possibly misinterpreted in the setting of interpersonal relationships. Put simply, it is possible that some patients with BPD may perceive and respond to subtle emotional cues that healthy subjects might otherwise ignore for the sake of socialization. The occurrence of this borderline empathy paradox has been related to a previous history of abuse during childhood, and is consistent with results of selected studies indicating enhanced emotional empathy and ToM.48,54,61,72,73,76,79,83,84,86,88 Along these lines, a proposed model explains the borderline empathy paradox resulting from a combination of increased attention to social stimuli and dysfunctional processing of social information,31 but the model needs to be confirmed. In addition, it is uncertain how patients with BPD interpret basic social information, and how well they use it to support interpersonal relationships.104
We did not include results of studies based on emotion-recognition tasks. Although this exclusion may be regarded as a limitation of the current review, it was intended to avoid possible confounds. As mentioned in the introduction, we consider emotion recognition as a prerequisite for empathy, but the possible occurrence of preserved or even enhanced emotion-recognition abilities is not necessarily a synonym of preserved empathy. In other words, although empathy and related processes are dependent on emotion recognition, an individual can be able to recognize emotions without being empathetic at all. We also did not include results of studies using unpublished105,106 or not generalizable assessment measures of empathy-related processes,107 and we did not include results of studies using other than “traditional ToM tasks.”108
Previous reviews have focused on dysfunction of empathy and related processes in patients with BPD.26,31,102,104,109–116 The major advantage of the present review relative to former ones is the inclusion of a larger number of studies assessing a wider range of psychological processes, using tools that help to explain the abnormal social functioning in patients with BPD. Furthermore, we separately reported the possible role of comorbidities and also considered findings of neuroimaging studies. Most previous reviews were either nonsystematic26,102,104,109,110,112 or had a different scope in terms of the addressed psychological processes.111,113–116 In particular, a substantial number of those reviews included studies on emotion recognition,31,104,112,116 and some were also devoted to psychiatric conditions other than BPD.111,114,116
The heterogeneity of samples and assessment measures, the different implementations of the latter, and the discrepancies among concepts underlying the addressed psychological processes correspond to limitations of this review, leading to a practical inability to calculate valid effect sizes or to take a meta-analytic approach. A possible strategy to deal with this particular limitation in the future could be to develop and implement research domain criteria117 as well as to use accurate, more homogeneous, and valid neuropsychological tools to assess empathic dysfunction in BPD.
Accordingly, no cutoffs to establish impaired empathic capacities in patients with BPD have been previously established in the literature, apart from a value of 4.5 reported by Morandotti and colleagues93 for the RFQ_U. It is relevant to point out that cutoff values have been previously proposed for tests applied to healthy subjects or in the setting of psychiatric conditions other than BPD. For instance, a cutoff of 30 has been proposed for the EQ in a study involving patients with Asperger’s syndrome or high-functioning autism.49 The current absence of cutoffs for the vast majority of tests assessing empathy or related processes represents a limitation in conveying validated information regarding salient differences between patients with BPD and healthy control subjects. Future original research studies aimed at resolving this issue are warranted.
Another limitation was the scarce number of neuroimaging studies using valid assessment measures and conditions designed to test empathy and related processes in BPD. Most probably, the results of these studies are not generalizable and did not specifically confirm the involvement of brain regions considered as part of the mirror neuron system in the process of empathic dysfunction. Curiously, one study not fulfilling inclusion criteria for this review revealed decreased activation in brain regions belonging to that system, as well as increased activation of the amygdala.118
Also of note is that published functional neuroimaging studies in BPD have been diverse in terms of their designs, paradigms, and conditions, with results that still need to be integrated into a single, coherent picture. For instance, studies not included in this review found increased activation of the following regions of the brain in BPD: frontal pole, medial prefrontal, frontal, anterior cingulate, and temporal-parietal cortices, as well as the precuneus and the superior and middle temporal gyri.85,119,120 Similarly, resting-state BOLD fMRI studies mostly reported decreased functional connectivity among several brain regions in patients with BPD.121,122
Structural neuroimaging studies have also been carried out in the setting of BPD. A widespread reduction of gray matter volume was demonstrated by using segmentation-based methods—including voxel-based morphometry and algorithms combining either analyses of cortical surface and sulci,123,124 or assessments of cortical thickness and source-based morphometry.125,126 Regional abnormalities (e.g., in the limbic system) were also reported.127,128 One study using diffusion tensor imaging revealed reduced fractional anisotropy of the inferior longitudinal fasciculus in adolescents, but not in adult patients, with BPD.129
Novel work is needed to clarify the underlying neurobiological mechanisms of empathy and related processes in patients with BPD via neuroimaging studies mapping psychopathology in combination with reliable neuropsychological assessment measures. Furthermore, it will be relevant to explore novel strategies to study neural substrates of social interaction in BPD. A key example here is hyperscanning—the use of simultaneous behavioral experiments in which participants can interact with each other while fMRI data are synchronously acquired from different scanners. With hyperscanning, a given pattern of brain activity can be consistently compared with the corresponding pattern of another brain.130 This sort of strategy would be especially well suited to evaluate trust and sensitivity to rejection in patients with BPD, given that lack of trust and an increased or inappropriate (i.e., maladaptive) rejection sensitivity occur in these patients, and might contribute to their pattern of abnormal social functioning.131,132 Furthermore, hyperscanning could be used to test the sense of belonging, acceptance, or inclusion of patients with BPD to specific social contexts.132 Another strategy that could provide similar advances is the “second-person neuroscientific approach” to study social interaction. In simple terms, second-person neuroscience refers to studies in which there are real-time interactions, as opposed to simply observational contexts (sometimes referred to as third-person neuroscience).133
Further proposed dimensions of empathy, such as the prosocial concern,134 and novel psychophysiological assessment measures, such as ecological momentary assessment,135,136 should also be brought to the fore to evaluate patients with BPD. Prosocial concern, as proposed by Zaki and Oshner,134 refers to an additional dimension to the concept of empathy, apart from “experience sharing” (largely related to emotional empathy) and “mentalizing” (largely related to cognitive empathy and ToM). By taking prosocial concern or motivation into account, it would be possible to assess how well an individual can help another on the basis of his own resources or both of theirs. Ecological momentary assessment involves a series of repeated measures of behaviors or physiological processes from participants engaging in real-life activities.135,136
In summary, a common finding in patients with BPD is dysfunction of empathy and related processes. This seems to contribute to their symptoms because a lack of cognitive or emotional empathy, ToM, mentalizing, social cognition, or emotional intelligence serves to preempt sustained social cooperation or to prevent its repair after disruption. In addition, enhanced emotional empathy or an excessive and inappropriate awareness of patients to emotions of others may occur. The authors postulate that such an inappropriate awareness might lead to emotional instability and intense personal (and interpersonal) distress, in keeping with results of numerous studies revealing increased scores in the personal distress subscale of the Interpersonal Reactivity Index. This conclusion further helps to explain the unstable interpersonal relationships of patients with borderline personality disorder.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
The authors are indebted to Margarida Figueiredo Braga and Rui Mota Cardoso for having strongly encouraged the writing of this review.
REFERENCES
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: APA, 2013.
2. Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet 2004;364:453–61.
3. Bachmann S. Epidemiology of suicide and the psychiatric perspective. Int J Environ Res Public Health 2018;15.
4. Gunderson JG. Disturbed relationships as a phenotype for borderline personality disorder. Am J Psychiatry 2007;164:1637–40.
5. Blair RJ. Responding to the emotions of others: dissociating forms of empathy through the study of typical and psychiatric populations. Conscious Cogn 2005;14:698–718.
6. Decety J, Meyer M. From emotion resonance to empathic understanding: a social developmental neuroscience account. Dev Psychopathol 2008;20:1053–80.
7. Preston SD, de Waal FB. Empathy: its ultimate and proximate bases. Behav Brain Sci 2002;25:1–20; discussion 20–71.
8. de Waal FBM, Preston SD. Mammalian empathy: behavioural manifestations and neural basis. Nat Rev Neurosci 2017;18:498–509.
9. Ekman P, Sorenson ER, Friesen WV. Pan-cultural elements in facial displays of emotion. Science 1969;164:86–8.
10. Davis MH. Measuring individual differences in empathy: evidence for a multidimensional approach. J Pers Soc Psychol 1983;44:113–26.
11. Gallese V. The ‘shared manifold’ hypothesis. From mirror neurons to empathy. J Conscious Stud 2001;8:33–50.
12. Gallese V. Before and below ‘theory of mind’: embodied simulation and the neural correlates of social cognition. Philos Trans R Soc Lond B Biol Sci 2007;362:659–69.
13. Dapretto M, Davies MS, Pfeifer JH, et al. Understanding emotions in others: mirror neuron dysfunction in children with autism spectrum disorders. Nat Neurosci 2006;9:28–30.
14. Premack D, Woodruff G. Does the chimpanzee have a theory of mind. Behav Brain Sci 1978;1:515–26.
15. Gallagher HL, Frith CD. Functional imaging of ‘theory of mind.’ Trends Cogn Sci 2003;7:77–83.
16. Shamay-Tsoory SG, Shur S, Barcai-Goodman L, Medlovich S, Harari H, Levkovitz Y. Dissociation of cognitive from affective components of theory of mind in schizophrenia. Psychiatry Res 2007;149:11–23.
17. Harari H, Shamay-Tsoory SG, Ravid M, Levkovitz Y. Double dissociation between cognitive and affective empathy in borderline personality disorder. Psychiatry Res 2010;175:277–9.
18. Bateman AW, Fonagy P. Mentalization-based treatment of BPD. J Pers Disord 2004;18:36–51.
19. Bateman A, Fonagy P. Comorbid antisocial and borderline personality disorders: mentalization-based treatment. J Clin Psychol 2008;64:181–94.
20. Choi-Kain LW, Gunderson JG. Mentalization: ontogeny, assessment, and application in the treatment of borderline personality disorder. Am J Psychiatry 2008;165:1127–35.
21. Sharp C, Pane H, Ha C, et al. Theory of mind and emotion regulation difficulties in adolescents with borderline traits. J Am Acad Child Adolesc Psychiatry 2011;50:563–73.e1.
22. Beer JS, Ochsner KN. Social cognition: a multi level analysis. Brain Res 2006;1079:98–105.
23. Herpertz SC. The social-cognitive basis of personality disorders: commentary on the special issue. J Pers Disord 2013;27:113–24.
24. Mayer JD, Caruso DR, Salovey P. Emotional intelligence meets traditional standards for an intelligence. Intelligence 1999;27:267–98.
25. Mayer JD, Salovey P, Caruso DR, Sitarenios G. Measuring emotional intelligence with the MSCEIT V2.0. Emotion 2003;3:97–105.
26. Jeung H, Herpertz SC. Impairments of interpersonal functioning: empathy and intimacy in borderline personality disorder. Psychopathology 2014;47:220–34.
27. Fonagy P. Thinking about thinking: some clinical and theoretical considerations in the treatment of a borderline patient. Int J Psychoanal 1991;72(pt 4):639–56.
28. Fonagy P, Leigh T, Steele M, et al. The relation of attachment status, psychiatric classification, and response to psychotherapy. J Consult Clin Psychol 1996;64:22–31.
29. Westen D. Social cognition and object relations. Psychol Bull 1991;109:429–55.
30. Bateman A, Fonagy P. Mentalization-based treatment. Psychoanal Inq 2013;33:595–613.
31. Dinsdale N, Crespi BJ. The borderline empathy paradox: evidence and conceptual models for empathic enhancements in borderline personality disorder. J Pers Disord 2013;27:172–95.
32. Krohn A. Borderline “empathy” and differentiation of object representations: a contribution to the psychology of object relations. Int J Psychoanal Psychother 1974;3:142–65.
33. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed., rev. Washington, D.C.: American Psychiatric Press, 1987.
34. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text rev. Washington, D.C.: APA, 2000.
35. World Health Organization. The international statistical classification of diseases and related health problems. 10th rev. Geneva: WHO, 1992.
36. Preißler S, Dziobek I, Ritter K, Heekeren HR, Roepke S. Social cognition in borderline personality disorder: evidence for disturbed recognition of the emotions, thoughts, and Intentions of others. Front Behav Neurosci 2010;4:182.
37. Happe FG. An advanced test of theory of mind: understanding of story characters’ thoughts and feelings by able autistic, mentally handicapped, and normal children and adults. J Autism Dev Disord 1994;24:129–54.
38. Fletcher PC, Happe F, Frith U, et al. Other minds in the brain: a functional imaging study of “theory of mind” in story comprehension. Cognition 1995;57:109–28.
39. Happe FG, Winner E, Brownell H. The getting of wisdom: theory of mind in old age. Dev Psychol 1998;34:358–62.
40. Arntz A, Bernstein D, Oorschot M, Schobre P. Theory of mind in borderline and cluster-C personality disorder. J Nerv Ment Dis 2009;197:801–7.
41. Yeh Z-T, Lin Y-C, Liu S-I, Fang C-K. Social awareness and its relationship with emotion recognition and theory of mind in patients with borderline personality disorder. J Soc Clin Psychol 2017;36:22–40.
42. Stone VE, Baron-Cohen S, Knight RT. Frontal lobe contributions to theory of mind. J Cogn Neurosci 1998;10:640–56.
43. Baron-Cohen S, O’Riordan M, Stone V, Jones R, Plaisted K. Recognition of faux pas by normally developing children and children with Asperger syndrome or high-functioning autism. J Autism Dev Disord 1999;29:407–18.
44. Baron-Cohen S, Wheelwright S, Hill J, Raste Y, Plumb I. The “Reading the Mind in the Eyes” Test revised version: a study with normal adults, and adults with Asperger syndrome or high-functioning autism. J Child Psychol Psychiatry 2001;42:241–51.
45. Harkness K, Sabbagh M, Jacobson J, Chowdrey N, Chen T. Enhanced accuracy of mental state decoding in dysphoric college students. Cogn Emot 2005;19:999–1025.
46. Scott LN, Levy KN, Adams RB Jr., Stevenson MT. Mental state decoding abilities in young adults with borderline personality disorder traits. Personal Disord 2011;2:98–112.
47. Schilling L, Wingenfeld K, Lowe B, et al. Normal mind-reading capacity but higher response confidence in borderline personality disorder patients. Psychiatry Clin Neurosci 2012;66:322–7.
48. Frick C, Lang S, Kotchoubey B, et al. Hypersensitivity in borderline personality disorder during mindreading. PLoS One 2012;7:e41650.
49. Baron-Cohen S, Wheelwright S. The empathy quotient: an investigation of adults with Asperger syndrome or high functioning autism, and normal sex differences. J Autism Dev Disord 2004;34:163–75.
50. Lawrence EJ, Shaw P, Baker D, Baron-Cohen S, David AS. Measuring empathy: reliability and validity of the empathy quotient. Psychol Med 2004;34:911–9.
51. Dziobek I, Fleck S, Kalbe E, et al. Introducing MASC: a movie for the assessment of social cognition. J Autism Dev Disord 2006;36:623–36.
52. Andreou C, Kelm L, Bierbrodt J, et al. Factors contributing to social cognition impairment in borderline personality disorder and schizophrenia. Psychiatry Res 2015;229:872–9.
53. Dziobek I, Rogers K, Fleck S, et al. Dissociation of cognitive and emotional empathy in adults with Asperger syndrome using the Multifaceted Empathy Test (MET). J Autism Dev Disord 2008;38:464–73.
54. Dziobek I, Preissler S, Grozdanovic Z, Heuser I, Heekeren HR, Roepke S. Neuronal correlates of altered empathy and social cognition in borderline personality disorder. Neuroimage 2011;57:539–48.
55. Ritter K, Dziobek I, Preissler S, et al. Lack of empathy in patients with narcissistic personality disorder. Psychiatry Res 2011;187:241–7.
56. Wingenfeld K, Kuehl LK, Janke K, et al. Enhanced emotional empathy after mineralocorticoid receptor stimulation in women with borderline personality disorder and healthy women. Neuropsychopharmacology 2014;39:1799–804.
57. Wingenfeld K, Duesenberg M, Fleischer J, et al. Psychosocial stress differentially affects emotional empathy in women with borderline personality disorder and healthy controls. Acta Psychiatr Scand 2018;137:206–15.
58. Fonagy P, Luyten P, Moulton-Perkins A, et al. Development and validation of a self-report measure of mentalizing: the reflective functioning questionnaire. PLoS One 2016;11:e0158678.
59. Langdon R, Michie PT, Ward PB, McConaghy N, Catts SV, Coltheart M. Defective self and/or other mentalising in schizophrenia: a cognitive neuropsychological approach. Cogn Neuropsychiatry 1997;2:167–93.
60. Langdon R, Coltheart M. Mentalising, schizotypy, and schizophrenia. Cognition 1999;71:43–71.
61. Petersen R, Brakoulias V, Langdon R. An experimental investigation of mentalization ability in borderline personality disorder. Compr Psychiatry 2016;64:12–21.
62. Brune M. Emotion recognition, ‘theory of mind,’ and social behavior in schizophrenia. Psychiatry Res 2005;133:135–47.
63. Ghiassi V, Dimaggio G, Brune M. Dysfunctions in understanding other minds in borderline personality disorder: a study using cartoon picture stories. Psychother Res 2010;20:657–67.
64. Bosco FM, Colle L, De Fazio S, Bono A, Ruberti S, Tirassa M. Th.o.m.a.s.: an exploratory assessment of theory of mind in schizophrenic subjects. Conscious Cogn 2009;18:306–19.
65. Bosco FM, Gabbatore I, Tirassa M, Testa S. Psychometric properties of the theory of mind assessment scale in a sample of adolescents and adults. Front Psychol 2016;7:566.
66. Langdon R, Ward PB, Coltheart M. Reasoning anomalies associated with delusions in schizophrenia. Schizophr Bull 2010;36:321–30.
67. Reniers RL, Corcoran R, Drake R, Shryane NM, Vollm BA. The QCAE: a questionnaire of cognitive and affective empathy. J Pers Assess 2011;93:84–95.
68. Hausberg MC, Schulz H, Piegler T, et al. Is a self-rated instrument appropriate to assess mentalization in patients with mental disorders? Development and first validation of the mentalization questionnaire (MZQ). Psychother Res 2012;22:699–709.
69. Dimitrijevic A, Hanak N, Altaras Dimitrijevic A, Jolic Marjanovic Z. The mentalization scale (MentS): a self-report measure for the assessment of mentalizing capacity. J Pers Assess 2018;100:268–80.
70. Niedtfeld I. Experimental investigation of cognitive and affective empathy in borderline personality disorder: effects of ambiguity in multimodal social information processing. Psychiatry Res 2017;253:58–63.
71. Regenbogen C, Schneider DA, Finkelmeyer A, et al. The differential contribution of facial expressions, prosody, and speech content to empathy. Cogn Emot 2012;26:995–1014.
72. Guttman HA, Laporte L. Empathy in families of women with borderline personality disorder, anorexia nervosa, and a control group. Fam Process 2000;39:345–58.
73. Fertuck EA, Jekal A, Song I, et al. Enhanced ‘Reading the Mind in the Eyes’ in borderline personality disorder compared to healthy controls. Psychol Med 2009;39:1979–88.
74. Hertel J, Schutz A, Lammers CH. Emotional intelligence and mental disorder. J Clin Psychol 2009;65:942–54.
75. Beblo T, Pastuszak A, Griepenstroh J, et al. Self-reported emotional dysregulation but no impairment of emotional intelligence in borderline personality disorder: an explorative study. J Nerv Ment Dis 2010;198:385–8.
76. New AS, aan het Rot M, Ripoll LH, et al. Empathy and alexithymia in borderline personality disorder: clinical and laboratory measures. J Pers Disord 2012;26:660–75.
77. Peter M, Schuurmans H, Vingerhoets AJ, Smeets G, Verkoeijen P, Arntz A. Borderline personality disorder and emotional intelligence. J Nerv Ment Dis 2013;201:99–104.
78. Baez S, Marengo J, Perez A, et al. Theory of mind and its relationship with executive functions and emotion recognition in borderline personality disorder. J Neuropsychol 2014.
79. Matzke B, Herpertz SC, Berger C, Fleischer M, Domes G. Facial reactions during emotion recognition in borderline personality disorder: a facial electromyography study. Psychopathology 2014;47:101–10.
80. Unoka ZS, Fogd D, Seres I, Keri S, Csukly G. Early maladaptive schema-related impairment and co-occurring current major depressive episode-related enhancement of mental state decoding ability in borderline personality disorder. J Pers Disord 2015;29:145–62.
81. Vaskinn A, Antonsen BT, Fretland RA, Dziobek I, Sundet K, Wilberg T. Theory of mind in women with borderline personality disorder or schizophrenia: differences in overall ability and error patterns. Front Psychol 2015;6:1239.
82. Hurtado MM, Trivino M, Arnedo M, Roldan G, Tudela P. Are executive functions related to emotional intelligence? A correlational study in schizophrenia and borderline personality disorder. Psychiatry Res 2016;246:84–8.
83. Flasbeck V, Enzi B, Brune M. Childhood trauma affects processing of social interactions in borderline personality disorder: an event-related potential study investigating empathy for pain. World J Biol Psychiatry 2017:1–11.
84. Flasbeck V, Enzi B, Brune M. Altered empathy for psychological and physical pain in borderline personality disorder. J Pers Disord 2017;31:689–708.
85. Homan P, Reddan MC, Brosch T, Koenigsberg HW, Schiller D. Aberrant link between empathy and social attribution style in borderline personality disorder. J Psychiatr Res 2017;94:163–71.
86. Martin F, Flasbeck V, Brown EC, Brune M. Altered mu-rhythm suppression in borderline personality disorder. Brain Res 2017;1659:64–70.
87. Perroud N, Badoud D, Weibel S, et al. Mentalization in adults with attention deficit hyperactivity disorder: comparison with controls and patients with borderline personality disorder. Psychiatry Res 2017;256:334–41.
88. Zabihzadeh A, Maleki G, Richman MJ, Hatami A, Alimardani Z, Heidari M. Affective and cognitive theory of mind in borderline personality disorder: the role of comorbid depression. Psychiatry Res 2017;257:144–9.
89. Anupama V, Bhola P, Thirthalli J, Mehta UM. Pattern of social cognition deficits in individuals with borderline personality disorder. Asian J Psychiatr 2018;33:105–12.
90. Badoud D, Prada P, Nicastro R, et al. Attachment and reflective functioning in women with borderline personality disorder. J Pers Disord 2018;32:17–30.
91. Berenson KR, Dochat C, Martin CG, Yang X, Rafaeli E, Downey G. Identification of mental states and interpersonal functioning in borderline personality disorder. Personal Disord 2018;9:172–81.
92. Grzegorzewski P, Kulesza M, Pluta A, Iqbal Z, Kucharska K. Assessing self-reported empathy and altruism in patients suffering from enduring borderline personality disorder. Psychiatry Res 2019:798–807.
93. Morandotti N, Brondino N, Merelli A, et al. The Italian version of the reflective functioning questionnaire: validity data for adults and its association with severity of borderline personality disorder. PLoS One 2018;13:e0206433.
94. Pluta A, Kulesza M, Grzegorzewski P, Kucharska K. Assessing advanced theory of mind and alexithymia in patients suffering from enduring borderline personality disorder. Psychiatry Res 2018;261:436–41.
95. Colle L, Gabbatore I, Riberi E, Borroz E, Bosco FM, Keller R. Mindreading abilities and borderline personality disorder: a comprehensive assessment using the theory of mind assessment scale. Psychiatry Res 2019;272:609–17.
96. Lind M, Thomsen DK, Boye R, Heinskou T, Simonsen S, Jorgensen CR. Personal and parents’ life stories in patients with borderline personality disorder. Scand J Psychol 2019.
97. Normann-Eide E, Antonsen BT, Kvarstein EH, Pedersen G, Vaskinn A, Wilberg T. Are impairments in theory of mind specific to borderline personality disorder? J Pers Disord 2019:1–15.
98. Van Heel M, Luyten P, De Meulemeester C, Vanwalleghem D, Vermote R, Lowyck B. Mentalizing based on external features in borderline personality disorder compared with healthy controls: the role of attachment dimensions and childhood trauma. J Pers Disord 2019:1–15.
99. Duque-Alarcon X, Alcala-Lozano R, Gonzalez-Olvera JJ, Garza-Villarreal EA, Pellicer F. Effects of childhood maltreatment on social cognition and brain functional connectivity in borderline personality disorder patients. Front Psychiatry 2019;10:156.
100. Peter M, Arntz AR, Klimstra T, Vingerhoets A. Different aspects of emotional intelligence of borderline personality disorder. Clin Psychol Psychother 2018;25:e51–9.
101. Zegarra-Valdivia JA, Chino Vilca BN. Social cognition and executive function in borderline personality disorder: Evidence of altered cognitive processes. Salud Mental 2019;42:33–42.
102. Roepke S, Vater A, Preissler S, Heekeren HR, Dziobek I. Social cognition in borderline personality disorder. Front Neurosci 2013;6:195.
103. King-Casas B, Sharp C, Lomax-Bream L, Lohrenz T, Fonagy P, Montague PR. The rupture and repair of cooperation in borderline personality disorder. Science 2008;321:806–10.
104. Lazarus SA, Cheavens JS, Festa F, Zachary Rosenthal M. Interpersonal functioning in borderline personality disorder: a systematic review of behavioral and laboratory-based assessments. Clin Psychol Rev 2014;34:193–205.
105. Brune M, Walden S, Edel MA, Dimaggio G. 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. Compr Psychiatry 2016;64:29–37.
106. Janke K, Driessen M, Behnia B, Wingenfeld K, Roepke S. Emotional intelligence in patients with posttraumatic stress disorder, borderline personality disorder and healthy controls. Psychiatry Res 2018;264:290–6.
107. Mehta UM, Thirthalli J, Naveen Kumar C, et al. Validation of Social Cognition Rating Tools in Indian Setting (SOCRATIS): a new test-battery to assess social cognition. Asian J Psychiatr 2011;4:203–9.
108. Franzen N, Hagenhoff M, Baer N, et al. Superior ‘theory of mind’ in borderline personality disorder: an analysis of interaction behavior in a virtual trust game. Psychiatry Res 2011;187:224–33.
109. Lis S, Bohus M. Social interaction in borderline personality disorder. Curr Psychiatry Rep 2013;15:338.
110. Ripoll LH, Snyder R, Steele H, Siever LJ. The neurobiology of empathy in borderline personality disorder. Curr Psychiatry Rep 2013;15:344.
111. Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders. Neurosci Biobehav Rev 2013;37:448–70.
112. Herpertz SC, Bertsch K. The social-cognitive basis of personality disorders. Curr Opin Psychiatry 2014;27:73–7.
113. Herpertz SC, Jeung H, Mancke F, Bertsch K. Social dysfunctioning and brain in borderline personality disorder. Psychopathology 2014;47:417–24.
114. Richman MJ, Unoka Z. Mental state decoding impairment in major depression and borderline personality disorder: meta-analysis. Br J Psychiatry 2015;207:483–9.
115. Nemeth N, Matrai P, Hegyi P, et al. Theory of mind disturbances in borderline personality disorder: a meta-analysis. Psychiatry Res 2018;270:143–53.
116. Rokita KI, Dauvermann MR, Donohoe G. Early life experiences and social cognition in major psychiatric disorders: a systematic review. Eur Psychiatry 2018;53:123–33.
117. Insel T, Cuthbert B, Garvey M, et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry 2010;167:748–51.
118. Mier D, Lis S, Esslinger C, et al. Neuronal correlates of social cognition in borderline personality disorder. Soc Cogn Affect Neurosci 2013;8:531–7.
119. Beeney JE, Hallquist MN, Ellison WD, Levy KN. Self-other disturbance in borderline personality disorder: neural, self-report, and performance-based evidence. Personal Disord 2016;7:28–39.
120. Vollm B, Richardson P, Stirling J, et al. Neurobiological substrates of antisocial and borderline personality disorder: preliminary results of a functional fMRI study. Crim Behav Ment Health 2004;14:39–54.
121. Das P, Calhoun V, Malhi GS. Bipolar and borderline patients display differential patterns of functional connectivity among resting state networks. Neuroimage 2014;98:73–81.
122. O’Neill A, D’Souza A, Samson AC, Carballedo A, Kerskens C, Frodl T. Dysregulation between emotion and theory of mind networks in borderline personality disorder. Psychiatry Res 2015;231:25–32.
123. Vollm BA, Zhao L, Richardson P, et al. A voxel-based morphometric MRI study in men with borderline personality disorder: preliminary findings. Crim Behav Ment Health 2009;19:64–72.
124. Rossi R, Lanfredi M, Pievani M, et al. Abnormalities in cortical gray matter density in borderline personality disorder. Eur Psychiatry 2015;30:221–7.
125. Depping MS, Wolf ND, Vasic N, Sambataro F, Thomann PA, Wolf RC. Common and distinct structural network abnormalities in major depressive disorder and borderline personality disorder. Prog Neuropsychopharmacol Biol Psychiatry 2016;65:127–33.
126. Boen E, Westlye LT, Elvsashagen T, et al. Regional cortical thinning may be a biological marker for borderline personality disorder. Acta Psychiatr Scand 2014;130:193–204.
127. Niedtfeld I, Schulze L, Krause-Utz A, Demirakca T, Bohus M, Schmahl C. Voxel-based morphometry in women with borderline personality disorder with and without comorbid posttraumatic stress disorder. PLoS One 2013;8:e65824.
128. Depping MS, Wolf ND, Vasic N, Sambataro F, Thomann PA, Christian Wolf R. Specificity of abnormal brain volume in major depressive disorder: a comparison with borderline personality disorder. J Affect Disord 2015;174:650–7.
129. New AS, Carpenter DM, Perez-Rodriguez MM, et al. Developmental differences in diffusion tensor imaging parameters in borderline personality disorder. J Psychiatr Res 2013;47:1101–9.
130. Montague PR, Berns GS, Cohen JD, et al. Hyperscanning: simultaneous fMRI during linked social interactions. Neuroimage 2002;16:1159–64.
131. Unoka Z, Seres I, Aspan N, Bodi N, Keri S. Trust game reveals restricted interpersonal transactions in patients with borderline personality disorder. J Pers Disord 2009;23:399–409.
132. Poggi A, Richetin J, Preti E. Trust and rejection sensitivity in personality disorders. Curr Psychiatry Rep 2019;21:69.
133. Redcay E, Schilbach L. Using second-person neuroscience to elucidate the mechanisms of social interaction. Nat Rev Neurosci 2019;20:495–505.
134. Zaki J, Ochsner KN. The neuroscience of empathy: progress, pitfalls and promise. Nat Neurosci 2012;15:675–80.
135. Trull TJ, Ebner-Priemer UW. Using experience sampling methods/ecological momentary assessment (ESM/EMA) in clinical assessment and clinical research: introduction to the special section. Psychol Assess 2009;21:457–62.
136. Santangelo P, Bohus M, Ebner-Priemer UW. Ecological momentary assessment in borderline personality disorder: a review of recent findings and methodological challenges. J Pers Disord 2014;28:555–76.
