New research
Theory of Mind and Emotion Regulation Difficulties in Adolescents With Borderline Traits

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Objective

Dysfunctions in both emotion regulation and social cognition (understanding behavior in mental state terms, theory of mind or mentalizing) have been proposed as explanations for disturbances of interpersonal behavior in borderline personality disorder (BPD). This study aimed to examine mentalizing in adolescents with emerging BPD from a dimensional and categorical point of view, controlling for gender, age, Axis I and Axis II symptoms, and to explore the mediating role of emotion regulation in the relation between theory of mind and borderline traits.

Method

The newly developed Movie for the Assessment of Social Cognition (MASC) was administered alongside self-report measures of emotion regulation and psychopathology to 111 adolescent inpatients between the ages of 12 to 17 (mean age = 15.5 years; SD = 1.44 years). For categorical analyses borderline diagnosis was determined through semi-structured clinical interview, which showed that 23% of the sample met criteria for BPD.

Results

Findings suggest a relationship between borderline traits and “hypermentalizing” (excessive, inaccurate mentalizing) independent of age, gender, externalizing, internalizing and psychopathy symptoms. The relation between hypermentalizing and BPD traits was partially mediated by difficulties in emotion regulation, accounting for 43.5% of the hypermentalizing to BPD path.

Conclusions

Results suggest that in adolescents with borderline personality features the loss of mentalization is more apparent in the emergence of unusual alternative strategies (hypermentalizing) than in the loss of the capacity per se (no mentalizing or undermentalizing). Moreover, for the first time, empirical evidence is provided to support the notion that mentalizing exerts its influence on borderline traits through the mediating role of emotion dysregulation.

Section snippets

Participants

All consecutive admissions (N = 132) to the Adolescent Treatment Program of a private tertiary care inpatient treatment facility were approached to participate in the study. The adolescent unit specializes in the evaluation and stabilization of adolescents who failed to respond to previous interventions. Inclusion criteria were ages between 12 and 17 years, English as a first language, and admission to the unit. A total of 21 subjects were excluded from the final analyses because of declining

Descriptive Statistics

Means, standard deviations, and ranges for all main study variables are summarized in Table 1.

Relation Between Mentalizing and Borderline Traits

Bivariate correlations between study variables are summarized in Table 2.

Table 2 shows that borderline traits were positively correlated with both Axis I (internalizing and externalizing problems) and psychopathic traits. Borderline traits were negatively correlated with the total ToM score (indicating reduced overall ToM/mentalizing capacity associated with increased borderline traits), which was

Discussion

This study is the first to use a ToM task that resembled the demands of everyday-life social cognition41 to examine mentalizing difficulties in relation to borderline traits in adolescents. Although other studies have investigated aspects of emotional processing in borderline youth,77 ours is the first to use a task specifically developed to assess mentalizing impairment in psychiatric disorder by considering potential dysfunctions of mentalizing such as insufficient mental state reasoning

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    Funding for the research was provided by the Child and Family Program at the Menninger Clinic.

    Disclosure: Dr. Sharp has received financial support from the National Institute of Mental Health, the National Alliance for Research on Schizophrenia and Depression Young Investigator Award, the Child and Family Program of the Menninger Clinic, a University of Houston Small Grant, and the South African Responsible Gambling Foundation. Dr. Fonagy has received financial support from the United Kingdom Department of Health, the Central and East London Comprehensive Local Research Network Program support for Systemic Therapy for At Risk Teens (START), the UK National Institute of Health Research Research for Patient Benefit Program, the National Institute for Clinical Excellence to British Psychological Society, the Hope for Depression Foundation, the UK Department for Children, Schools, and Families, and the UK National Health Technology Assessment program. Ms. Ha, Ms. Pane, Ms. Venta, and Drs. Patel and Sturek report no biomedical financial interests or potential conflicts of interest.

    This article is discussed in an editorial by Drs. Marianne Goodman and Larry J. Siever on page 536.

    Supplemental material cited in this article is available online.

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