Journal of Personality Disorders, 29, 2015, 181

© 2015 The Guilford Press

ATTRIBUTIONAL “TUNNEL VISION”

IN PATIENTS WITH BORDERLINE
PERSONALITY DISORDER
Lisa Schilling, MS, Steffen Moritz, PhD, Brooke Schneider, PhD, Julia
Bierbrodt, MS, and Matthias Nagel, MD

We aimed to examine the profile of interpersonal attributions in BPD. We

hypothesized that patients show more mono-causal and internal attribu-
tions than healthy controls. A revised version of the Internal, Personal,
Situational and Attributions Questionnaire was assessed in 30 BPD patients
and 30 healthy controls. BPD patients and controls differed significantly in
their attributional pattern. Patients displayed more mono-causal inferences,
that is, they had difficulties considering alternative explanatory factors.
For negative events, patients made more internal attributions compared
to healthy controls. We concluded that mono-causal “trapped” thinking
might contribute to (interpersonal) problems in BPD patients by fostering
impulsive consequential behaviors, for example, harming one’s self or oth-
ers. A self-blaming tendency likely promotes depressive symptoms and low
self-esteem.

Attributional style has been defined as the way in which one explains the
cause of (social) events in terms of oneself, others, or circumstances (Kaney
& Bentall, 1989). Depending on what is identified as the main cause of a
positive or negative situation (e.g., always blaming others or always blaming
oneself), consequences for one’s own affective states and behavioral responses
arise. Attributional patterns have been thoroughly examined for both depres-
sion and schizophrenia (e.g., Candido & Romney, 1990; Kinderman & Ben-
tall, 1997; Moritz, Woodward, Burlon, Braus, & Andresen, 2007) and have
been linked with symptoms. Specifically, patients with depression show a
self-blaming tendency, that is, they make particularly internal, global, and
stable attributions for negative events (e.g., Fresco, Alloy, & Reilly-Harrington,
2006). In contrast, two recent studies found that patients with acute paranoid
schizophrenia displayed a tendency to externalize blame in response to both

From Department of Psychiatry and Psychotherapy, Asklepios Clinic Nord-Wandsbek, Hamburg, Ger-
many (L. S., M. N.); Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-
Eppendorf, Hamburg, Germany (L. S., S. M., B. S., J. B.); and Department of Psychiatry and Psychotherapy,
University of Luebeck, Luebeck, Germany (M. N.).
Address correspondence to Lisa Schilling, MS, Asklepios Clinic Nord-Wandsbek, Department of Psychiatry
and Psychotherapy, Juethornstr. 71, 22043 Hamburg, Germany. E-mail: l.schilling@asklepios.com

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 2 SCHILLING ET AL.

positive and negative events (Lincoln, Mehl, Exner, Lindenmeyer, & Rief,
2010; Randjbar, Veckenstedt, Vitzthum, Hottenrott, & Moritz, 2010). This
patient group predominantly identified only a single causal factor for an event.
Restricted information processing and the jumping to conclusion bias were
considered as explanations for mono-causal reasoning (Lincoln et al., 2010;
Randjbar et al., 2010).
In borderline personality disorder (BPD), a number of cognitive biases
have been found to interfere with social interaction (Baer, Peters, Eisenlohr-
Moul, Geiger, & Sauer, 2012; Lazarus, Cheavens, Festa, & Rosenthal, 2014).
Several studies have reported that patients with BPD make negativistic and
schema-related evaluations of others (for a summary, see Sieswerda, Barnow,
Verheul, & Arntz, 2013). Moreover, patients with BPD show dichotomous
thinking in that they tend to judge other people in an extreme (positive and
negative) manner (Arntz & ten Haaf, 2012; Arntz & Veen, 2001; Napoli-
tano & McKay, 2007; Veen & Arntz, 2000). Interestingly, BPD patients do
not provide just “simple” or “automatic” explanations for the behavior of
others, but their explanations tend to be as complex as those of healthy
controls (Arntz & ten Haaf, 2012). Westen (1991) described that inaccuracy
in explaining situations is a characteristic attributional pattern in BPD and
is an outcome of social learning history. For example, if a patient perceived
his or her parents’ behavior as capricious and hard to predict, the develop-
ment of the ability to arrive at differentiated and valid attributions would
be hampered (Westen, Ludolph, Block, Wixom, & Wiss, 1990). Moreover,
“egocentrism”—that is, an “embeddedness in one’s own point of view”—was
identified as another important feature. Patients with BPD seem to regard
themselves as the predominant cause of events (Westen, 1991). In addition,
relatively harmless events are catastrophized because only a univalent (nar-
row) representation can be activated (e.g., “He is going to leave me, because
I am worthless”). Interestingly, in a study by Moritz and colleagues (2011),
patients made more mono-causal inferences compared to healthy controls,
supporting the assumption of a “tunnel vision.” Unlike people with depres-
sion, patients with BPD might make such global attributions relating to
themselves and others also for positive events. In accordance, Moritz and
colleagues (2011) showed that BPD patients tended to allocate a larger
proportion (in percent) of the cause of both positive and negative events
to themselves compared to healthy controls. The excessive internalization
of success and failure may account for the egocentrism mentioned above
(Moritz et al., 2011; Westen, 1991).
On the basis of the limited empirical studies on causal reasoning in BPD,
the aims of this study were: (1) to compare the pattern of causal reasoning
in a group of BPD patients and healthy persons; given the recent findings,
we hypothesized that patients would show a more egocentric attributional
pattern than controls, that is, they would endorse a greater proportion of the
attribution of positive and negative events to themselves; (2) to replicate the
finding of mono-causal attributions; (3) to explore the relationship of symp-
tomatology with attributions; and (4) to analyze whether comorbid depressive
symptoms influence attributional processes in BPD.

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 ATTRIBUTIONAL STYLE IN BORDERLINE PATIENTS 3

METHODS
PARTICIPANTS
The sample was comprised of 30 patients with BPD and 30 healthy controls.
Patients were recruited through the Department of Psychiatry and Psycho-
therapy, University Medical Center Hamburg-Eppendorf, Germany. Healthy
subjects were drawn from an existing subject pool or word of mouth. Written
informed consent was obtained from all participants. BPD diagnoses were
verified using the Structured Clinical Interview for DSM-IV (SCID) part II for
personality disorders (First, Gibbon, Spitzer, Williams, & Benjamin, 1997). The
global severity of BPD symptomatology was assessed with the short version
of the Borderline Symptom List (BSL-23; Bohus et al., 2009). This instrument
has proven to be valid in discriminating borderline patients from other psychi-
atric groups (mean d = 1.13). Internal consistency (Cronbach’s alpha .93–.97)
and test-retest reliability (r = .82, p < .0001) are high (Bohus et al., 2009).
The German version of the Beck Depression Inventory (BDI; Beck & Steer,
1993) was administered to assess the severity of depressive symptoms (in the
last seven days). The instrument shows good internal consistency, test-retest
reliability, and construct validity (Beck, Steer, & Garbin, 1988). Premorbid
intelligence was measured using the multiple-choice vocabulary test (MWT-B;
Lehrl, 1995). The MWT-B correlates fairy well with global IQ, median of r =
.72 (Lehrl, Triebig, & Fischer, 1995).
Exclusion criteria in the BPD group were cognitive impairment, intelli-
gence quotient < 70, current or lifetime schizophrenia, alcohol or drug depen-
dence (last 6 months), bipolar disorder, schizoaffective disorder, and major
depression with psychotic symptoms as assessed by the Mini International
Neuropsychiatric Interview (MINI; Sheehan et al., 1998). The absence of
mental disorders in healthy participants was verified with the MINI. Patients
were only included if there was no change in psychopharmacological medica-
tion for at least two weeks.

INTERNAL, PERSONAL AND SITUATIONAL

ATTRIBUTIONS QUESTIONNAIRE – REVISED
Based on the Attributional Style Questionnaire (ASQ; Peterson et al., 1982),
Kinderman and Bentall (1996) developed the Internal, Personal and Situational
Attributions Questionnaire (IPSAQ), a causal reasoning assessment instrument
that focuses on the importance of interpersonal relations. The ASQ covers only
two causal loci (internal versus external). In the IPSAQ, the subject should
endorse if the explanation is predominantly associated with oneself (internal),
others (external-personal), or circumstances (external-situational). Kinder-
man and Bentall (1996) reported Cronbach’s alphas for the subscales of the
original 32-item version of the IPSAQ between .61 and .76. For the present
study, a revised shortened (16-item) German version of the IPSAQ was used.
The instrument was translated into German and then back-translated by a
native speaker. This version was already used with patients with schizophrenia
and BPD (Moritz et al., 2010, 2011). Evidence for discriminant validity of the

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 4 SCHILLING ET AL.

revised IPSAQ-R was assessed in the work of Moritz and colleagues (2010).
Patients are presented with eight positive (e.g., “A friend thinks you are inter-
esting”) and eight negative (e.g., “A friend ignored you”) verbal events. First,
subjects are asked to write down the core reason that led to this event (e.g.,
“He does not like me”). Subjects were additionally asked to specify the rela-
tive contribution of personal and situational factors in percent (e.g., myself:
30%, others: 58%, circumstances: 12%). Ratings are assumed as mono-causal
if one of the three item options received at least 80%.

Statistical analyses. Statistical analyses were conducted using SPSS Version

21.0. An alpha level of .05 (two-tailed) was used for all statistical tests. Be-
tween-group comparisons were performed by means of the t-test and χ2-test.
Analyses of covariance were performed to control for possible confounding
variables. Correlational analyses were conducted to determine the relationship
of different attributional patterns with BPD symptom severity.

RESULTS
PARTICIPANTS
Group samples did not differ in age, education, or intelligence (see Table 1);
however, we included more female patients than female healthy controls, χ2(59)
= 4.59, p = .032. The MINI revealed that nineteen BPD patients currently had
depression. Twenty-three of the 30 patients were treated with psychotropic
medication.

ATTRIBUTIONAL STYLE
We conducted a three-way mixed ANOVA with the factors “Event-Type”
(positive, negative) and “Attribution” (myself, other persons, circumstances)
as within-subject factors and “Group” (healthy, BPD patients) as the between-
subject factor.
The main effect “Attribution” reached significance, F(2, 58) = 84.86, p <
.001, η2partial = .59, indicating that attributions on internal, external-personal,
and situational factors were different. The three-way interaction “Event-Type”
× “Attribution” × “Group,” F(2, 58) = 8.36, p <. 001, η2partial = .13, was signifi-
cant, indicating that groups differed in their attributional patterns (see Figure
1). Compared to healthy controls, patients with BPD attributed the cause of
negative events to themselves significantly more, t(58) = 2.82, p = .007, and
attributed the cause of negative events to situational factors significantly less,
t(58) = 2.17, p = .034. At a trend level, patients with BPD showed increased
attributions to circumstances for positive events, t(58) = 1.85, p = .070. Healthy
controls displayed a trend toward increased internal attributions for positive
events compared to patients, t(58) = 1.95, p = .056.
Mono-causal attribution of positive events to others was negatively
correlated with the severity of borderline symptomatology (BSL-23), r =
–.51, p = .009, and with depressive symptoms, r = –.49, p = .012. For nega-
tive events, mono-causal inferences to others correlated with severity of

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 ATTRIBUTIONAL STYLE IN BORDERLINE PATIENTS 5

TABLE 1.  Sociodemographic and Psychopathological

Characteristics of the Samples
BPD Controls Statistics
Age (years) 31.43 (7.95) 32.97 (10.88) t(58) = .623, p = .536, n.s.
Gender (male/female) 7/23 15/15 χ2(59) = 4.59, p = .032
Years of education 12.01 (1.50) 11.85 (1.69) t(58) = –.404, p = .687, n.s.
BDI 29.1 (9.29) 2.7 (2.52) t(38) = –10.698, p < .001

BSL-23 2.05 (.77) not assessed —

Note. BDI = Beck Depression Inventory, BPD = Borderline Personality Disorder, BSL-23 =
Borderline Symptom List 23.

borderline symptomatology, r = .48, p = .008. No other correlation reached

significance.
When controlling for the possible effect of depression, the interaction
“Event-Type” × “Attribution” × “Group” was no longer significant, F(2, 58)
= 1.23, p = .298, indicating that depressive symptomatology influenced attri-
butional pattern for positive and negative situations. The interaction between
“Depressive Symptomatology” × “Attribution” showed a trend, F(2, 58) =
2.51, p = .088. Re-analyses of the data controlling for the possible confounder
“Gender” yielded the following findings. The interaction “Event Type” ×

FIGURE 1.  Attributional style. BPD patients made fewer internal attributions
for positive events but allocated a larger proportion of the causation of negative
events to themselves than did healthy controls.

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 6 SCHILLING ET AL.

“Attribution” × “Gender,” F(2, 58) = 1.85, p = .175, was not significant.

However, the interaction “Event type” × “Attribution” × “Group” still reached
significance, F(2, 58) = 10.06, p < .001, indicating that groups differed in their
attributional patterns for positive and negative events and that gender did not
significantly influence this result.

MONO-CAUSAL REASONING
Overall, patients made significantly more mono-causal attributions for posi-
tive (t(58) = 2.48, p = .016) and for negative events, t(58) = 2.55, p = .013. In
particular, patients displayed more mono-causal inferences for negative events
relating to themselves, t(58) = 2.79, p = .007 and more mono-causal attribu-
tions for positive events relating to others, t(58) = 2.80, p = .007.

DISCUSSION

In BPD, interpersonal conflicts and turbulent relationships have been linked

with difficulties finding balanced explanations for the reasons underlying
other people’s behavior and dichotomous thinking (Arntz & ten Haaf, 2012).
Therefore, we aimed to explore attributional style in BPD patients in com-
parison to healthy controls. Our hypothesis of a more egocentric attributional
style (increased sense of self-causation) as reported by Westen (1991) and
Moritz and colleagues (2011) could not be replicated. However, in accordance
with Moritz and colleagues (2011), patients made significantly more mono-
causal attributions for both positive and negative events, which might support
the assumption of dichotomous thinking with mixed (positive and negative)
valences in BPD (Arntz & ten Haaf, 2012). Consequently, tunnel vision (i.e.,
failure to consider alternative interpretations) may foster impulsive acts (inter-
personal conflicts due to feeling offended) as patients might hastily commit
to a single explanatory cause preventing retrieval of alternative explanations.
Enhanced mono-causal attributions have also been found in schizophrenia
patients (Randjbar et al., 2010). However, in contrast to patients who are
acutely deluded, BPD patients displayed no enhanced externalizing tendency.
Like patients who are depressed, patients with BPD showed a self-blaming
tendency for negative events but hardly considered situational factors. That is,
they viewed themselves as responsible for negative events. Internalization of
failure might promote the experience of anger toward oneself and the feeling
of loneliness (or a perceived lack of support), eventually increasing depression
symptoms or self-injurious behavior or low self-esteem. We found no evidence
for a negativistic attitude or a tendency to blame others among those with BPD.
There are limitations to our study. First, the reliability and validity of
the IPSAQ-R should be examined for future studies. Some of the items of
the IPSAQ might not have been clearly positive or negative for BPD patients
(e.g., receiving a compliment might also be experienced as aversive). More-
over, attributional processes for borderline-relevant or personally meaning-
ful events (e.g., confrontation with interpersonal threats or rejection) versus
neutral events might differ (Arntz, Weertman, & Salet, 2011). Thus, we plan

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 ATTRIBUTIONAL STYLE IN BORDERLINE PATIENTS 7

to develop a causal reasoning instrument that comprises more BPD-relevant

items and asks patients to provide the personal meaning of events.
Regarding specificity of results, future studies should include a patient
control group, for example, BPD patients with and without current depres-
sion. It should also be tested with other measurements, such as a handheld
PC, whether attributions are stable or vary depending on emotional state.
Further, in addition to evidence-based standard treatment, such as dialectical
behavioral therapy (Linehan, 1993), patients with BPD might benefit from
complementary add-on (meta-)cognitive training which focuses on some of the
newly uncovered BPD-specific dysfunctional thinking styles and thus extends
existing treatment programs with useful (cognitive) elements.
To summarize, the main results of this study were that BPD patients
showed mono-causal reasoning and a self-blaming tendency.

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