REVIEW

CURRENT
OPINION The social-cognitive basis of personality disorders
Sabine C. Herpertz and Katja Bertsch

Purpose of review
The review summarizes recent results on abnormalities in social cognition in patients with personality
disorders that predispose them to develop dysfunctional interaction with others. The review starts with more
basic social cognition processes, such as emotion recognition and reactions to social exclusion that are
followed by more complex processes such as cognitive and affective empathy.
Recent findings
The deficits in social cognition depend on the particular function that is investigated and is strongly
associated with characteristic symptoms of particular personality disorders. Thus, patients with borderline
personality disorder are hypersensitive for social threat, they show deficits in cognitive empathy and high
emotion contagion, that is, they share emotions of others without properly discriminating between one’s
own feelings and those of others. Psychopaths are characterized by deficiency in facial fear recognition
and emotional empathy similar to patients with narcissistic personality disorder. Studies on social cognition
in cluster A and C personality disorders are sparse.
Summary
Research indicates deficits in social cognition in patients with personality disorders, but more research is
needed to investigate social cognition in cluster A and C personality disorders and to compare deficits in
social cognitive functions across personality disorders.
Keywords
empathy, facial emotion recognition, moral judgment, rejection sensitivity, trust appraisal

INTRODUCTION are generally subsumed under cognitive empathy or

During the past two decades, issues of affect regu-
lation and impulse control have dominated research
questions in the field of personality disorders. Mean-
while, disturbed relationships are thought to be a
theory of mind. In contrast, emotional empathy
denotes emotion sharing and social executive con-
trol to regulate this experience and to keep track of
the origins of self and other feelings [2]. In their
&

third prominent sector of psychopathology in indi-
viduals meeting the criteria of a personality dis-
order, borderline personality disorder (BPD), in
particular. A fearful or highly reactive interpersonal
style has been suggested to be a highly distinctive
and pathogenic component of BPD psychopatho-
review on social cognition in BPD Roepke et al. [3 ]
claim that BPD individuals are characterized by
systematic negative, malevolent biases in their inter-
actions with others, that they exhibit subtle deficits
in appropriate emotional responses to others and
that they show ambiguous, hard to read social sig-
&

logy, often designed as interpersonal hypersensi-
tivity. In addition, dichotomous thinking as a
prominent characteristic of BPD patients’ evalu-
ations of others may contribute to interpersonal
&
dysfunction in BPD [1 ]. In this review, we focus
on abnormalities in social cognition in patients with
personality disorders that predispose them to
develop dysfunctional interaction with others.
Humans have to interpret other people’s
internal states by analyzing external cues, particu-
larly facial expressions. They also apply learnt cog-
nitive models of how an individual is expected to
experience specific situations in order to infer other
people’s goals and predict their actions. Both aspects
nals in the interaction to others. Mak and Lamm [4 ]
conclude that a ‘hypermentalizing’ tendency may
contribute to BPD individuals’ socially inappropri-
ate interaction with others, as well as a difficulty to
disengage attention from threatening cues.
Department of General Psychiatry, Center for Psychosocial Medicine,
University of Heidelberg, Heidelberg, Germany
Correspondence to Sabine C. Herpertz, MD, Department of General
Psychiatry, Center for Psychosocial Medicine, University of Heidelberg,
Heidelberg, Vossstr. 2, 69115 Heidelberg, Germany. Tel: +49 6221
5622751; e-mail: sabine.herpertz@uni-heidelberg.de
Curr Opin Psychiatry 2014, 27:73–77
DOI:10.1097/YCO.0000000000000026

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Personality disorders
KEY POINTS
 Patients with borderline personality disorder are
hypersensitive for social threat and they consistently
show deficits in cognitive empathy.
 Patients with borderline personality disorder exhibit
enhanced unconscious emotional simulation processes
resulting in high emotion contagion.
 Psychopaths are characterized by deficiency in facial
fear recognition and emotional empathy.
Antisocial individuals are thought to show
deficits in the recognition of negative emotional
facial expressions, although they may be good
at perceiving others’ intentions [5]. As antisocial
personality disorder is rather a heterogeneous diag-
nostic entity, this finding was found to be more
stringently associated with the psychopathy sub-
type, which, according to Hare [6], is characterized
by emotional detachment, callousness, and egocen-
tricity. Individuals with narcissistic personality dis-
order (NPD) were shown to exhibit deficits in
affective empathy [7].
The article reviews the recent data on social
cognitive functions in personality disorders apply-
ing a Pubmed search using the following keywords:
‘borderline personality disorder’, ‘antisocial person-
ality disorder’, ‘narcissistic personality disorder’,
‘psychopathy’, ‘social cognition’, ‘empathy’, ‘theory
of mind’, ‘facial emotion recognition’, ‘trust
(appraisal)’, ‘rejection sensitivity’, ‘moral judg-
ment’, and ‘moral decision making’.
FACIAL EMOTION RECOGNITION
The recognition of facial emotions is a basic and
immediate competence that is crucial for successful
interpersonal interaction. From a clinical perspect-
ive, patients with BPD have been regarded as hyper-
sensitive for subtle cues of social threat and rejection.
Experimental data on facial emotion recognition,
however, appear rather inconsistent and seem to
heavily depend on task specificities, such as presen-
tation time, intensity of facial emotions, and type of
instruction, as well as on the dependent variables
(e.g. response latencies, error rates). On the basis of a
&&
systematic meta-analysis, Daros et al. [8 ] conclude
that BPD patients’ typical enhanced arousal may be
responsible for their hypersensitivity to subtle facial
cues of negative emotions, that is, they recognize
negative emotions faster and more correct in faces
that are presented briefly or display the emotion in a
low intensity. As the increased arousal may hinder
the disentangling of attention from the emotion, this
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could also explain impairments in, that is, slower and
less correct, recognition of negative facial emotions
that are shown for longer time periods or in full
intensity compared to healthy controls. Consistent
with previous reviews (e.g. [9]), this meta-analysis
also revealed no general deficit in emotion recog-
nition, but rather a particular impairment in the
recognition of fully displayed angry, but also neutral
and disgusting facial expressions in BPD patients.
As manual reaction times only represent a rather
late measure of conscious emotion recognition [10],
researchers have started to additionally measure eye
movements, electrophysiological correlates, and
brain activations in response to emotional facial
expressions. Apart from an enhanced amygdala acti-
vation for facial, and particularly angry facial,
&& &
expressions [11 ,12,13 ], which might be related
&
to the patients’ enhanced trait anxiety [13 ] or
&&
history of early (emotional) maltreatment [14 ],
BPD patients have been found to show more and
faster initial, reflexive eye movements towards the
eyes, and thus the most threatening and arousing
&&
region of very briefly presented angry faces [11 ].
This latter study also revealed that a single dose of
intranasally administered synthetic oxytocin –
which, across species, exerts stress-reducing, anxio-
lytic-like effects – may alter the hypersensitivity for
facial threat in BPD by reducing the speed and
amount of initial eye movements towards angry
eyes as well as the amygdala’s responsiveness for
angry faces. In addition to enhanced amygdala
responses, recent findings also indicate alterations
in the activity of frontal areas and the fronto-limbic
connectivity for negative facial emotions in BPD
patients compared to healthy controls. Thus, BPD
patients showed increased activity in the dorsal and
rostral anterior cingulate cortex for fearful versus
&
neutral facial distractors [13 ], and enhanced con-
nectivity between bilateral amygdala and rostral
anterior cingulate cortex for faces displaying overt
fear compared to healthy individuals [15].
Regarding antisocial personality disorder, and
particularly psychopathy, there is strong evidence
for impairments in the recognition of several facial
emotions including fear and sadness in adults as
well as children and adolescents (for review, see
&&
[16 ]). This has been associated with blunted amyg-
dala responses (for review, see [17]) and a reciprocal
reduction in the functional connectivity between
the amygdala and visual as well as prefrontal corti-
ces, and hence deficits in the integration of
emotions into cognition in psychopaths [18].
Little is known about facial emotion recognition
in NPD. First results from the study by Marissen et al.
&
[19 ] indicate that although patients with NPD
regard themselves as sensitive for the feelings of
Volume 27  Number 1  January 2014
 Social-cognitive basis of personality disorders Herpertz and Bertsch
others, they show general deficits in the recognition
of facial emotions with greatest impairments in the
recognition of fear and disgust compared to healthy
controls and patients with cluster C personality
disorders. Thus, very first experimental findings
point to a combination of subjective overestimation
of and objective deficits in basic social cognitive
abilities in patients with NPD.
TRUST APPRAISAL AND REJECTION
SENSITIVITY
Social cognition not only relies on the recognition
of facial emotions but also on the appraisal of
personality traits, such as trustworthiness, that are
closely related to emotion recognition but also
require more sophisticated social judgments.
Patients with BPD have been found to be highly
sensitive to social rejection (e.g. [20,21]). This hyper-
sensitivity may help to avoid actual experiences of
social rejection and may thus reduce dysphoric and
painful social events, which are experienced more
intensely by patients with BPD [22]. In line with
this, Fertuck et al. [23] recently found a bias to
appraise neutral faces less trustworthy as well as
slower reaction times for faces with ambiguous
trustworthiness in patients with BPD. The patients
did not differ either in measures of sensitivity or
discriminability from healthy controls or in the
appraisal of facial fear, which may indicate that this
bias may be typical of BPD. So far, the results of two
studies indicate that, at least in trust games, the
intranasal administration of oxytocin does not
improve trust and the experienced trustworthiness
in patients with BPD [24,25]. The results of these
studies and those of Fertuck et al. [23] additionally
emphasize the role of individual differences within
groups of patients with personality disorders, such
as BPD. Thus, attachment style [24] and childhood
traumatization [23,25] have to be considered when
investigating trust, facial trust appraisal, and rejec-
tion sensitivity, at least in BPD.
COGNITIVE EMPATHY
Despite some inconsistencies in findings, data from
experimental psychopathology suggest impaired
cognitive theory of mind abilities in patients with
BPD (for review, see [26]). Weak perspective taking is
already reflected in self-report measurements, such
as the Interpersonal Reactivity Index [27]. This
is particularly true when patients are assessed by
more complex, more difficult, and ecologically valid
measurements. Interestingly, in the Reading the
Mind in the Eyes (RME) test, BPD patients show
&&
equal [28] or even enhanced [29,30 ] performance
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compared to healthy controls. It should, however, be
noted that the performance in the RME test does not
require an explicit meta-representation that is the
representation of another person’s thought process,
but can rather be resolved by strategies other than
mentalizing, including simulating processes.
Functional neuroimaging studies may deepen
our understanding of theory of mind deficiencies
in BPD patients. Several studies report decreased
neuronal activity in the superior temporal gyrus,
the superior temporal sulcus, and the precuneus,
and thus central structures of the social brain
involved in representing and predicting the actions
and social intentions of other people from an
analysis of biological-motion cues (for review, see
[31,32]). These abnormally low activations were
found while BPD patients performed the Multifac-
eted Empathy Test [33] and the Social–Cognitive task
&&
[34 ], both of which challenge theory of mind pro-
cesses. Interestingly, lower neuronal activation in the
theory of mind circuit was also found during the RME
&&
test [30 ], supporting the assumption that BPD
patients – despite good performance in this task –
did not apply cognitive mentalizing strategies.
In psychopaths, previous findings permit only
a partial understanding of potential empathy
deficiencies. On the basis of a precise and ecologically
valuable laboratory measurement – the empathic
accuracy paradigm – criminal psychopaths exhibited
&&
impaired cognitive empathy [35 ]. Psychopathy
turned out to be negatively correlated with empathic
accuracy, particularly with regard to negatively
valenced emotions. The authors suggest from the
pattern of findings in psychopaths a failure of more
complex, dynamic, and interactive processing of
others’ emotions rather than of the processing of
simple static social stimuli.
AFFECTIVE EMPATHY
&
Similar to previous studies (for a review, see [36 ]),
New et al. [27] found enhanced self-reported
emotional distress in social contexts in BPD patients
using the Interpersonal Reactivity Scale. In addition,
the record of electromyographic activity during
facial emotion perception revealed increased acti-
vity of the musculus corrugator supercilii in BPD
patients when confronted with faces displaying
&
anger, sadness, or disgust [37 ], but lower activity
of the musculus levator labii in response to happy
and surprised faces. This may indicate a high auto-
matic simulation in individuals with BPD while
viewing faces which reflect emotional states similar
but not different to one’s own.
There is consistent evidence for enhanced amyg-
dala activations during tasks requiring affective
www.co-psychiatry.com 75
 Personality disorders
empathy in patients with BPD compared to healthy
&& &&
volunteers [30 ,34 ]. In the Social–Cognitive task,
BPD patients additionally showed a task-independ-
&&
ent hyperactivity in the somatosensory cortex [34 ]
that may indicate enhanced unconscious emotional
simulation processes. In the RME test, areas con-
nected with the amygdala and prefrontal cortex,
such as the left temporal pole, the middle temporal
gyrus, and the medial frontal gyrus, showed
&&
increased activations in patients with BPD [30 ].
During the affective empathy condition of the
Multifaceted Empathy Test (MET), BPD patients
were characterized by enhanced right mid-insular
activity [33], which is known to co-occur with self-
oriented emotional reactions to others and
emotional distress in the observer (for review, see
[38]), whereas in the RME test, anterior insular
activity, which is a key mediator of the other-ori-
ented sharing of emotions (for a review, see [39]),
&&
was lower in BPD patients than in controls [30 ].
Psychopathy is conceptualized to reflect a lack
of empathy and remorse, and blunted responding to
emotional cues. Correspondingly, structural neuro-
imaging data found specific abnormalities in crim-
inal offenders with psychopathy as opposed to those
without psychopathy in cortical regions implicated
in empathic processing and moral reasoning, that
is, in the anterior rostral prefrontal cortex and
&&
temporal poles [40 ] and in midline cortical areas
&
[41]. However, Domes et al. [42 ] could not confirm
their hypothesis of defective emotional empathy to
be specific for adult psychopathic offenders, but
rather found low cognitive and emotional empathy
in criminal offenders in general, irrespective of the
level of psychopathy.
Although lack of empathy is also a core symp-
tom of NPD, empathy has hardly been investigated
in this population. The only existing experimental
study revealed deficits in emotional empathy, but
unimpaired cognitive empathy in patients with
NPD compared to healthy individuals and patients
with BPD [6].
MORAL JUDGMENT AND DECISION-
MAKING
So far, moral judgment and decision-making have
been mainly investigated in psychopaths with
psychopathy, predicting utilitarian decisions in
moral dilemma situations (e.g. [43]), possibly related
with reduced activity in the ventromedial prefrontal
cortex [44]. Thus, psychopathic individuals are
more likely to choose effective options that may
cause harm for other individuals. Results, how-
ever, remain less consistent regarding moral judg-
ment. Whereas some studies found no associations
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between psychopathy and moral judgment [43],
others revealed impaired moral judgments in psy-
chopaths linked with hypoactivations in the dorso-
&
lateral prefrontal cortex [45 ]. Apart from this,
psychopaths have been reported to show impair-
ments in identifying own behaviors that may cause
fear in others and in judging the moral acceptability
of these behaviors [46].
CONCLUSION
Social cognitive dysfunction is at the heart of the
concept of personality disorder. However, research
is still at the initial stage. Future studies may aim at
developing experimental designs that are closer to
the complex, dynamic, and often equivocal nature
of social interactions in the real world, using multi-
modal stimuli and the possibilities of virtual reality.
In addition to dyadic interactions, social cognitive
functions have to be investigated in social groups
with various protagonists covering different prob-
lem areas of individuals with personality disorders
in the private and professional life, also consider-
ing issues of age and sex. Social cognition closely
interacts with affect regulation and the function-
ing of the self, leading to interesting questions
for future research. Finally, a deeper understand-
ing of social cognitive dysfunction and its inter-
actions with other personality domains will help to
further elaborate psychotherapeutic and pharma-
cological treatments for this significant group of
patients.
Acknowledgements
None.
Conflicts of interest
This work was supported by two grants of the German
Research Foundation to S.C.H. on borderline personality
disorder (Clinical Research Group on Mechanisms of
Disturbed Emotion Processing in Borderline Personality
Disorder: He 2660/12–1; He 2660/7–2).
Both authors have no conflicts of interest to declare.
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