The role of impairments in self–other distinction in borderline personality disorder: a narrative review of recent evidence

Impairments in maintaining a differentiated sense of “self” and “other” are thought to be a central feature of borderline personality disorder (BPD). However, studies directly focusing on self–other distinction (SOD) in BPD are scarce, and these findings have not yet been integrated with novel insights into the neural mechanism involved in SOD. Here, we present a narrative review of recent behavioral and neuroimaging findings focusing on impairments in SOD in BPD. Behavioral findings of SOD at the embodied level provide preliminary evidence for impairments in multisensory integration in BPD. Furthermore, both behavioral and neuroscientific data converge to suggest that SOD impairments in BPD reflect an inability to shift between self and other representations according to task demands. Research also suggests that disruptions in infant–caregiver synchrony may play a role in the development of these impairments. Based on these findings, we present a new, integrative model linking impairments in SOD to reduced neural and behavioral synchrony in BPD. The implications of these findings for future research and clinical interventions are outlined

Mentalizing as a Mechanism of Change in the Treatment of Patients With Borderline Personality Disorder: A Parallel Process Growth Modeling Approach.

Although a number of effective psychotherapeutic treatments have been developed for borderline personality disorder (BPD), little is known about the mechanisms of change explaining the effects of these treatments. There is increasing evidence that impairments in mentalizing or reflective functioning-the capacity to reflect on the internal mental states of the self and others-are a central feature of BPD. To date, no study has directly investigated the core assumption of the mentalization-based approach to BPD, that changes in this capacity are associated with treatment outcome in BPD patients. This study is the first to directly investigate this assumption in a sample of 175 patients with BPD who received long-term hospitalization-based psychodynamic treatment. Using a parallel process growth modeling approach, this study investigated whether (a) treatment was related to changes in mentalizing capacity as measured with the Reflective Functioning Questionnaire; (b) these changes could be explained by pretreatment levels of mentalizing and/or symptomatic distress; and (c) changes in mentalizing capacity over time were associated with symptomatic improvement. Mentalizing and symptomatic distress were assessed at admission, 12 and 24 weeks into treatment, and at discharge. Results showed that treatment was associated with significant decreases in mentalizing impairments (i.e., uncertainty about mental states) and symptomatic distress. Pretreatment levels of mentalizing and symptomatic distress did not predict these changes. However, improvements in mentalizing were strongly associated with the rate of decrease in symptomatic distress over time (r = .89). These findings suggest that increases in mentalizing may indeed in part explain therapeutic change in the treatment of BPD, but more research is needed to further substantiate these conclusions. (PsycINFO Database Recor

Self–other distinction and borderline personality disorder features: Evidence for egocentric and altercentric bias in a self–other facial morphing task

Self–other distinction (SOD) refers to the ability to distinguish one’s own body, actions, and mental representations from those of others. Problems with SOD are considered to be a key feature of borderline personality disorder (BPD). However, empirical studies on SOD in BPD are scarce. Here, we present a study providing preliminary support for the usefulness and validity of a self–other facial morphing task to capture the capacity for SOD in a sample of nonclinical participants high (n = 30) and low (n = 32) in BPD features. Participants had to watch a video sequence in which their own face was gradually morphed into the face of an unfamiliar other (self-to-other) or vice versa (other-to-self), requiring them to indicate at which point they judged the morph to look more like the target face than the starting face. Consistent with predictions, results showed that participants in the high-BPD group judged the morph to look like themselves for longer in the self-to-other direction (suggestive of egocentric bias), but only with a relatively more attractive target face. In the other-to-self direction, the high-BPD group had more difficulty recognizing their own face (i.e., an altercentric bias), but this time only with the relatively less attractive face. Further research is needed to replicate these findings in clinical samples, but overall they suggest that the current task might be suited to investigate SOD problems in BPD. (PsycInfo Database Record (c) 2020 APA, all rights reserved

Mechanisms of Change Through the Lens of Two-Polarities Models of Personality Development: State of the Art and New Directions

This article reviews moderators and mediators of therapeutic change through the lens of the two-polarities model of personality development. This psychodynamic model of personality development essentially proposes that personality development involves a continuous dialectic interaction between the development of the capacity for relatedness on the one hand and agency and self-definition on the other. Within this model, vulnerability for psychopathology is thought to result from an excessive emphasis on one developmental line and the defensive avoidance of the other. The two-polarities model also proposes a unified, transdiagnostic approach to therapeutic change in that it suggests that effective interventions, regardless of the brand name, lead to a reactivation of the dialectic interaction between the development of relatedness and self-definition through experiences of mutuality and understanding, as well as separation and misunderstanding in the therapeutic relationship, much as in normal personality development. We summarize research relevant to this view, and illustrate how this empirically based model of personality development and the therapeutic process may inform clinical practice. We focus specifically on recent developments within this model, which have led to a major shift in our thinking regarding the role of specific and common factors in explaining therapeutic change. We illustrate this shift in our thinking by way of a discussion of emerging research findings concerning therapeutic change in both brief and longer-term treatments across different therapeutic modalities. Limitations of the model are reviewed, and suggestions for future research are discussed

Do my emotions show or not? Problems with transparency estimation in women with borderline personality disorder features

Transparency estimation, that is, estimating the extent to which one’s mental states are observable to others, requires the simultaneous representation of the self and of others’ perspective on the self. Individuals with borderline personality disorder (BPD) have difficulty integrating multiple perspectives when mentalizing, which may be reflected in impaired transparency estimation. A total of 62 participants high and low in BPD features watched emotionally evocative video clips and estimated the transparency of their emotional experience while facial expression coding software (FaceReader) quantified their objective transparency. Individuals high in BPD features showed a larger discrepancy between estimated and objective transparency than individuals low in BPD features, showing that they both over- and underestimated their transparency. Indeed, estimated transparency positively predicted objective transparency in individuals low in BPD features, but not in individuals high in BPD features. Moreover, the ability to estimate intraindividual variability in one’s own objective transparency was moderated by self-reported arousal in the participants high in BPD features. Impairments in transparency estimation were correlated with self-report measures of borderline features, attachment, and mentalizing. In conclusion, we found that borderline features relate to a reduced capacity to estimate the extent to which one’s own emotional states are observable to others. Although replication in clinical samples of BPD patients is needed, the present study provides evidence for problems in mentalizing the (embodied) self from another person’s perspective in BPD

What's in a Face? Mentalizing in Borderline Personality Disorder Based on Dynamically Changing Facial Expressions

The mentalization-based approach to borderline personality disorder (BPD) argues that impairments in mentalizing are a key feature of BPD. Most previous research in this area has concentrated on potential impairments in facial emotion recognition in BPD patients. However, these studies have yielded inconsistent results, which may be attributable to methodological differences. This study aimed to address several limitations of previous studies by investigating different parameters involved in emotion recognition in BPD patients using a novel, 2-step dynamically changing facial expression paradigm, taking into account the possible influence of mood, psychotropic medication, and trauma exposure. Twenty-two BPD patients and 22 matched normal controls completed this paradigm. Parameters assessed were accuracy of emotion recognition, reaction time (RT), and level of confidence, both for first and full response and for correct and incorrect responses. Results showed (a) that BPD patients were as accurate in their first, but less accurate in their full emotion recognition than normal controls, (b) a trend for BPD patients to respond more slowly than normal controls, and (c) no significant difference in overall level of confidence between BPD patients and normal controls. Mood and psychotropic medication did not influence these results. Exposure to trauma in BPD patients, however, was negatively related to accuracy at full expression. Although further research is needed, results suggest no general emotion-recognition deficit in BPD patients using a dynamic changing facial recognition paradigm, except for a subgroup of BPD patients with marked trauma who become less accurate when they have to rely more on controlled, reflective processes

Self-critical perfectionism, dependency, and symptomatic distress in patients with personality disorder during hospitalization-based psychodynamic treatment: A parallel process growth modeling approach

There is growing evidence for the efficacy and effectiveness of psychotherapy in patients with personality disorder (PD), but very little is known about the factors underlying these effects. Two-polarities models of personality development provide an empirically supported approach to studying therapeutic change. Briefly, these models argue that personality pathology is characterized by an imbalance between development of the capacity for self-definition and for relatedness, with an exaggerated emphasis on issues regarding self-definition and relatedness being expressed in high levels of self-critical perfectionism (SCP) and dependency, respectively. This study used data from a study of 111 patients with PD who received long-term hospitalization-based psychodynamic treatment to investigate whether (a) treatment was related to changes in SCP, dependency, and symptomatic distress; (b) these changes could be explained by pretreatment levels of SCP, dependency, and/or symptomatic distress; and (c) changes in these personality dimensions over time were associated with symptomatic improvement. SCP, dependency, and symptomatic distress were assessed at admission (baseline), at 12 and 24 weeks into treatment, and at discharge. Parallel process multilevel growth modeling showed that (a) treatment was associated with a significant decrease in levels of SCP, dependency, and symptomatic distress, whereas (b) pretreatment levels of each of these three factors did not predict the decreases observed, and (c) changes in SCP, but not dependency, were associated with the rate of decrease in symptomatic distress over time. Implications of these findings for our understanding of therapeutic change in the treatment of PD are discussed

Development and validation of a self-report measure of mentalizing: The Reflective Functioning Questionnaire

Reflective functioning or mentalizing is the capacity to interpret both the self and others in terms of internal mental states such as feelings, wishes, goals, desires, and attitudes. This paper is part of a series of papers outlining the development and psychometric features of a new self-report measure, the Reflective Functioning Questionnaire (RFQ), designed to provide an easy to administer self-report measure of mentalizing. We describe the development and initial validation of the RFQ in three studies. Study 1 focuses on the development of the RFQ, its factor structure and construct validity in a sample of patients with Borderline Personality Disorder (BPD) and Eating Disorder (ED) (n=108) and normal controls (n=295). Study 2 aims to replicate these findings in a fresh sample of 129 patients with personality disorder and 281 normal controls. Study 3 addresses the relationship between the RFQ, parental reflective functioning and infant attachment status as assessed with the Strange Situation Procedure (SSP) in a sample of 136 community mothers and their infants. In both Study 1 and 2, confirmatory factor analyses yielded two factors assessing Certainty (RFQ_C) and Uncertainty (RFQ_U) about the mental states of self and others. These two factors were relatively distinct, invariant across clinical and non-clinical samples, had satisfactory internal consistency and test–retest stability, and were largely unrelated to demographic features. The scales discriminated between patients and controls, and were significantly and in theoretically predicted ways correlated with measures of empathy, mindfulness and perspective-taking, and with both self-reported and clinician-reported measures of borderline personality features and other indices of maladaptive personality functioning. Furthermore, the RFQ scales were associated with levels of parental reflective functioning, which in turn predicted infant attachment status in the SSP. Overall, this study lends preliminary support for the RFQ as a screening measure of reflective functioning. Further research is needed, however, to investigate in more detail the psychometric qualities of the RFQ

Mentalizing and interpersonal problems in borderline personality disorder: The mediating role of identity diffusion

Individuals with borderline personality disorder (BPD) are characterized by problems in interpersonal functioning and their long-term social integration often remains problematic. Extant theories have linked identity diffusion to many of the interpersonal problems characteristic of BPD patients. Recent theoretical accounts have suggested that identity diffusion results from problems with mentalizing or reflective functioning, that is, the capacity to understand oneself and others in terms of intentional mental states. In this study we tested these assumptions, i.e., whether identity diffusion plays a mediating role in the relationship between mentalizing difficulties and interpersonal problems, in a sample of 167 BPD patients. Highly significant correlations were found between mentalizing impairments, identity diffusion and interpersonal problems. Mediation analyses showed that identity diffusion fully mediated the relationship between mentalizing difficulties and interpersonal problems. This study provides preliminary evidence that impairments in mentalizing are related to identity diffusion, which in turn is related to interpersonal problems in BPD. Further longitudinal research is needed to further substantiate these conclusions