Author’s Accepted Manuscript

Affective and cognitive theory of mind abilities in

youth with borderline personality disorder or major
depressive disorder

Sarah-Ann Tay, Carol A. Hulbert, Henry J.

Jackson, Andrew M. Chanen
www.elsevier.com/locate/psychres

PII: S0165-1781(16)30783-1
DOI: http://dx.doi.org/10.1016/j.psychres.2017.06.016
Reference: PSY10563
To appear in: Psychiatry Research
Received date: 4 May 2016
Revised date: 1 June 2017
Accepted date: 4 June 2017
Cite this article as: Sarah-Ann Tay, Carol A. Hulbert, Henry J. Jackson and
Andrew M. Chanen, Affective and cognitive theory of mind abilities in youth
with borderline personality disorder or major depressive disorder, Psychiatry
Research, http://dx.doi.org/10.1016/j.psychres.2017.06.016
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 Affective and cognitive theory of mind abilities in youth with borderline personality
disorder or major depressive disorder
Sarah-Ann Taya, Carol A Hulberta*, Henry J Jacksona, Andrew M Chanenb,c,d
a
Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne,
Australia
b
Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Australia
c
Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
d
Orygen Youth Health, Northwestern Mental Health, Melbourne, Australia
*
Corresponding Author: Melbourne School of Psychological Sciences, The University of
Melbourne, Parkville 3010, VIC, Australia. cah@unimelb.edu.au

Abstract

Background:

Theory of mind (ToM) is an important social cognitive ability that has been investigated in

BPD, with inconsistent findings indicating impaired, comparable, and enhanced ToM in

BPD. This study aimed to clarify and extend previous findings by investigating affective and

cognitive ToM abilities in youth early in the course of BPD, by including a clinical

comparison group of youth with major depressive disorder (MDD).

Methods:

Female participants aged 15 – 24 years diagnosed with BPD (n = 41) or MDD (n = 37)

completed the Reading the Mind in the Eyes Test (RMET) and Happé’s Cartoon Task,

measures of affective and cognitive dimensions of ToM, respectively.

Results:

The BPD group performed significantly worse than the MDD group on the affective ToM

task, even after controlling for age, intelligence and depressive symptoms. Results for

cognitive ToM were not significantly different.

Conclusions:

Finding of poorer performance on a measure of affective ToM, in BPD youth, relative to

youth with MDD early in the course of BPD suggest a developmental failure of

sociocognitive abilities needed for mentalising and which are theorised as giving rise to core
features of BPD. Future research should employ more naturalistic paradigms to study social

cognition and should assess individuals even earlier in the course of BPD.

Keywords: Borderline Personality Disorder, theory of mind, mentalisation, social cognition

1. Introduction
Borderline personality disorder (BPD) is a severe mental disorder that is characterised by a

pervasive pattern of impulsivity, along with instability in emotion regulation, interpersonal

relationships and self-image (Leichsenring et al., 2011). The interpersonal features of BPD

have received increasing emphasis in recent years (Herpertz, 2013), and dysfunction in social

cognition has been proposed to account for the severe interpersonal difficulties experienced

by people with BPD (e.g., Sharp and Fonagy, 2008).

Social cognition is a broad construct, encompassing processes such as emotion recognition,

theory of mind (ToM), and empathy, which contribute to an individual’s capacity to

understand and to respond effectively to others’ thoughts and feelings (Herpertz, 2013). ToM

refers to an individual’s ability to attribute mental states (e.g., thoughts, feelings, beliefs,

intentions) to accurately predict and explain another person’s behaviour (Premack and

Woodruff, 1978). Mentalising is a closely related concept (Choi-Kain and Gunderson, 2008),

which is defined as the mental process by which an individual perceives and interprets the

actions of others and themselves in terms of intentional mental states (e.g., thoughts, feelings,

wishes, desires, beliefs and reasons; Allen, Fonagy, and Bateman, 2008; Fonagy and

Bateman, 2008). Despite several key distinctions between the two constructs (see Choi-Kain

and Gunderson, 2008), the terms ‘mentalising’ and ‘ToM’ are often used interchangeably

(Sharp et al., 2011).

ToM can be separated into cognitive and affective components (Shamay-Tsoory et al., 2007).
Affective ToM refers to the capacity to understand others’ emotional states, and cognitive

ToM refers to the ability to reason about other people’s beliefs (Shamay-Tsoory et al., 2007).

False belief tasks are regarded as a prototypical assessment of cognitive ToM, as they require

individuals to infer that another person’s behaviour will be directed by their beliefs, even if

they are based on misinformation about the environment (Poletti et al., 2012; Wimmer and

Perner, 1983). On the other hand, the Reading the Mind in the Eyes Task (RMET; Baron-

Cohen et al., 2001) is considered a prototypical measure of affective ToM (Poletti et al.,

2012). The RMET involves making subtle discriminations of others’ complex affective

mental states, based on pictures of the eye region only.

Two studies of cognitive ToM, each using different methodologies, yielded inconsistent

results. Relative to healthy controls, BPD patients were found to display comparable

performance (Ghiassi, Dimaggio, and Brüne, 2010) on a cartoon task (Brüne, 2005), and

enhanced performance (Arntz et al., 2009) on the advanced ToM test (Happé et al., 1996).

Findings using the RMET to assess affective ToM in BPD, also, have been inconsistent. Two

clinical studies found that adults with BPD performed significantly better than healthy

controls on the RMET (Fertuck et al., 2009; Frick et al., 2012), as did a study of a non-

clinical sample of university students with features of BPD (Scott et al., 2011). However, two

clinical studies (Preiler et al., 2010; Schilling et al., 2012) did not find differences in

performance on the RMET between adults with BPD and healthy controls. Taken together,

RMET studies seem to indicate intact or enhanced affective ToM ability in BPD, with

discrepancies reported also in terms of whether BPD individuals show sensitivity toward a

particular affective valence, and the potential influence of depression on RMET performance

(Fertuck et al., 2009).

Only two studies have simultaneously examined affective and cognitive ToM, also with

inconsistent results (Harari et al., 2010; Preiler et al., 2010). The first used story vignettes in

the Understanding Faux Pas task (Baron-Cohen et al., 1997) and found evidence of impaired

cognitive ToM in BPD patients, compared with healthy controls (Harari et al., 2010).

However, there were no significant differences between the groups on affective ToM,

suggesting dissociation between cognitive and affective ToM in BPD. The second study

(Preiler et al., 2010) used the Movie for the Assessment of Social Cognition (MASC;

Dziobek et al., 2006), a computerised, video-based test, designed to simulate the social

cognitive demands of everyday life that allows assessment of overmentalising, as well as

reduced ToM. The authors found recognition impairments in all three aspects of feelings,

thoughts, and intentions in patients with BPD, indicating impairment in both cognitive and

affective ToM. Two studies used the MASC (Dziobek et al., 2006) in adolescents with BPD

(Sharp et al., 2011, 2013) and found a strong association between an “excessive ToM” or

“hypermentalising” response (i.e., over-interpretative mental state reasoning) and BPD

features in adolescents, independent of internalising and externalising problems, with

impairments reported in both cognitive and affective ToM.

Not all studies of ToM in BPD have distinguished between affective and cognitive

components of ToM. In an investigation of virtual social exchange (Franzen et al., 2011),

BPD patients displayed superior attribution of mental states to interaction partners, while

non-patients disregarded a partner’s fairness when emotional cues were present.

In summary, studies of ToM capacities in BPD have yielded seemingly inconsistent findings.

Some studies have documented overall impairments in ToM (Preiβler et al., 2010), and more
specifically in cognitive ToM (Harari et al., 2010). Other studies argue against mentalising

impairment in BPD, finding better ToM performance (Arntz et al., 2009; Franzen et al.,

2011), excessive ToM (Sharp et al., 2011, 2013), or comparable mentalising ability (Ghiassi

et al., 2010). RMET studies in particular, have indicated enhanced (Fertuck et al., 2009; Frick

et al., 2012; Scott et al., 2011) or intact (Preiβler et al., 2010; Schilling et al., 2012) mental

state decoding or affective ToM ability in BPD. In short, gross deficiencies in ToM do not

appear to be evident in BPD, relative to healthy controls (Richman and Unoka, 2015). Rather,

there appears to be a trend towards equivalent or enhanced ToM in BPD patients in relation

to affective ToM and mental state decoding (Fertuck et al., 2009; Harari et al., 2010) but

compromised cognitive aspects of ToM (Harari et al., 2010; Preiβler et al., 2010).

Three possible explanations for these discrepant findings include measurement issues, failure

to account for the role of personality pathology and severity and/or specific co-occurring

psychopathologies, such as mood disorder and post-traumatic stress disorder, and failure to

distinguish the developmental stage and phase of disorder.

Some studies have used more traditional ‘offline’ cartoon- or story-based assessment

methods (e.g., Arntz et al., 2009; Ghiassi et al., 2010; Harari et al., 2010), whereas another

study used a simulated social interaction situation (Franzen et al., 2011). Even studies using

the MASC might not be directly comparable with one another, with different components of

participants’ responses being examined in different studies. Another possible explanation is

the influence of emotional arousal and interpersonal context on social cognition in BPD

(Fonagy and Luyten, 2009), which might vary, depending upon the type of task utilised.
Social cognition research across various diagnostic groups indicates a complex array of

diagnosis-specific effects, along with severity of disorder and comorbidity-related effects

(e.g., Andreou et al., 2015; Lee et al., 2005; Semerai et al., 2014, 2015; Unoka et al, 2014;

Unoka et al., 2015; Vaskinn et al., 2015; Wang et al., 2008). For example, the results of a

recent meta-analysis indicated that relative to healthy controls, schizophrenia and major

depressive disorder (MDD), were associated with greater ToM impairment than BPD, with

differences identified also in the patterns of impairments found for each group (Richman and

Unoka, 2015). The authors noted, also, that participants with both BPD and MDD were more

accurate in RMET assessments than those with BPD or MDD alone. Given that MDD

commonly co-occurs with BPD, including in youth (Chanen et al., 2007), these findings have

relevance for the investigation of the contributions of mood and ToM to the enduring social

dysfunction found in BPD. For, example, adult MDD groups demonstrated poorer

performance in detecting positive valence on the RMET while those with BPD fared worse

with neutral stimuli (Richman and Unoka, 2015). Additionally, participants with BPD and

co-occurring cluster B or C personality disorders were more impaired than those with BPD

only. These findings, together with findings from Semerai and colleagues (2015) showing

greater metacognitive impairment in patients with any personality disorder diagnosis

(compared to healthy controls) and associations with personality disorder type and severity,

indicate more complex patterns of influences than considered thus far.

Lastly, in much of this research there has been a lack of clarity about the influence of age,

developmental stage, extent of prior treatment and other characteristics among BPD

participants. For example, studies of adults have used samples with full-syndrome BPD,

whereas those of adolescents have used inpatients with a mixture of sub-syndromal and full

syndrome BPD (Scott et al., 2011; Sharp et al., 2011; 2013). Moreover, the adolescent groups
employed by Sharp et al. were from a specialised inpatient unit where patients typically have

lengthy prior treatment histories, had high comorbidity with MDD, and were of above

average intelligence. Both the adult and adolescent samples in these studies might be

influenced differentially by duration of illness effects (Chanen et al., 2013), such as

polypharmacy, other treatments, and cumulative adverse events and mental state disorders.

Also, prior research has shown that being older (Astington and Jenkins, 1995), and having

higher intelligence are associated with better ToM performance (Astington and Jenkins,

1999). Likewise, the co-occurrence of BPD and MDD in adults was associated with greater

accuracy on the RMET, compared to responses of those with BPD alone (Richman & Unoka.

2015).

The research context for the present study includes a focus on clinical research with the

potential to guide early intervention with youth with BPD, including those with acute

presentations including high levels of risk related to self -harm and suicide and mood

disorder. Hence, the primary aims of the present study were: (1) to investigate the specificity

of affective and cognitive ToM abilities in community-treated acutely unwell youth,

presenting early in the course of BPD, relative to a clinical comparison group of community-

treated youth with MDD screened for personality disorder; (2) to adjust for potentially

confounding variables, such as age, intelligence, and severity of depression; and (3) to use

measures that would allow comparisons with previous studies in BPD and other conditions.

The RMET was utilised as a measure of affective ToM. Cognitive ToM was assessed using

Happé’s Cartoon Task (Happé et al, 1999), a measure that demands mental state reasoning.

Noting the very limited ToM research comparing youth with MDD and BPD, the very mixed

findings from BPD studies utilising healthy controls, and findings from studies of adults with

MDD showing poorer ToM overall than those with BPD (e.g., Richman & Unoka, 2015) it
was predicted that, compared with MDD participants, individuals with BPD would show

higher accuracy on both the RMET, and Happé’s Cartoon Task. The study also explored the

effects of comorbid post-traumatic stress disorder within the BPD group on RMET and

Happe’s Cartoon task.

2. Method
2.1 Participants
Two groups (N = 78) of female participants between the ages of 15 and 25 years were

recruited from two government-funded youth mental health services in western metropolitan

Melbourne, Australia. Orygen Youth Health (OYH) is funded by the Victorian State

Government and headspace Western Melbourne is funded by the Federal Government. Only

females were recruited in order to avoid potential sex effects on social cognition (Baron-

Cohen, 2003).

The BPD group comprised 41 youth recruited from Helping Young People Early (HYPE;

Chanen et al., 2009), a specialised early intervention program for BPD at OYH. Participants

met Structured Clinical Interview for DSM-IV (SCID) Axis II disorders (SCID-II; First et al.,

1997b) criteria for BPD. The BPD module of the SCID-II was completed as part of the

routine HYPE entry assessment by treating clinicians, who are specifically trained in BPD

assessment, using a rigorous standard that has been published elsewhere (Lawrence, Allen,

and Chanen, 2010). These clinicians also administered the Structured Clinical Interview for

DSM-IV Axis I disorders, patient version (SCID-I/P; First et al., 1997a) as part of this

assessment. Thirty five BPD participants (84.5%) met criteria for a mood disorder, while 16

(39%) met criteria for PTSD (see Table 1). Exclusion criteria were a schizophrenia-spectrum

or affective psychotic disorder, psychiatric condition due to a medical condition, inadequate

English comprehension, or a severe disturbance that might interfere with their ability to give
informed consent or adhere to the study protocol.

The comparison group comprised 37 youth who were recruited from the Youth Mood Clinic

at Orygen Youth Health and from headspace. Participants met SCID-I/P criteria for MDD in

the past 12 months. An initial telephone screen was conducted for BPD and antisocial

features, prior to the invitation to participate in the study, using the SCID-II Personality

Questionnaire (SCID-II-PQ; First et al., 1997b) and clinical diagnoses were extracted from

participants’ medical files. In addition to the exclusion criteria applied to the BPD group,

participants were excluded if they had 3 or more SCID-II BPD features, any antisocial PD

features, or if they met full diagnostic criteria for any other DSM-IV personality disorder.

2.2 Measures
2.21 Screening measures for control participants

The SCID-II PQ (First et al., 1997b) uses a Yes/No response format. For the present study,

the 15 BPD items and the 15 items corresponding to Criterion A for antisocial PD were used.

2.22 Depression

Depression severity was rated using the 20-item Centre for Epidemiologic Studies

Depression Scale – Revised (CESD-R; Eaton, Smith, Ybarra, Muntaner, and Tien, 2004). The

CESD-R has excellent internal consistency and good or excellent convergent and divergent

validity (Eaton et al., 2004; Van Dam and Earleywine, 2011). In the current study, internal

consistency was excellent (Cronbach’s α = 0.93).

2.23 Intelligence and attention

IQ was measured with the Wechsler Abbreviated Scale of Intelligence (WASI; Wechsler,

1999) two-subtest form. Vocabulary and Matrix Reasoning subtests were used to derive a T-
score for Verbal IQ and Performance IQ, respectively. The sum of T-scores on these two

subscales was used to obtain age-corrected Full Scale IQ. A Digit Span task was also

administered to assess participants’ level of attention. The WASI has good to excellent

psychometric properties (Wechsler, 1999).

Affective ToM

The RMET consists of 36 black and white photographs of the eye region of faces. For each

item, participants are presented with a pair of eyes and asked to choose from four complex

mental state descriptors (i.e., one correct word and three distracter words) the word that best

describes the eyes. The RMET complex mental state descriptors were selected on the basis

that they went beyond basic emotions ( fear, sadness) and allowed the identification of an

attribution of intention (e.g., jealousy, suspiciousness) (Baron-Cohen et al., 2001). There is

no time limit to this task and participants were provided with a glossary. Following Baron-

Cohen et al. (2001), each participant evaluated the same set of RMET stimuli in the same

sequence. Scores are calculated by adding up the total number of correct mental state

attributions for all 36 items. Additionally, to examine mental state decoding accuracy for

stimuli of particular emotional valence, the 36 RMET stimuli were classified into positive

(nine items), neutral (17 items), and negative (10 items) valence categories based on the

classification system used by Scott et al. (2011).

Cognitive ToM

Happé’s Cartoon Task (Happé et al., 1999) has been described as a more “traditional” ToM

task that probes cognitive ToM, as it demands “thinking about thinking” and deductive

reasoning skills (Russell et al., 2009, p. 182). The task consists of 12 single-frame cartoons.

Six cartoons make up the ToM or mental state inference condition (MS), requiring the
participant to utilise understanding of the character’s beliefs or intentions (e.g., false belief or

ignorance) to accurately explain the humour, and six physical state (PS) cartoons make up the

non-mental control condition, in which the humour only involves recognition of physical

anomalies or violation of a social norm. Four cartoons in the MS set and four in the PS set

displayed facial expressions. Six cartoons (three MS and three PS) included captions that

were read aloud to participants. Cartoons were presented in random order, one at a time, and

participants were asked to explain why each was funny. Answers were recorded and scored

according to a standard scoring scheme in which 3 is given for a full and explicit explanation,

2 for a partial/implicit explanation, and 1 for reference to relevant parts of the cartoon without

further explanation. Irrelevant, incorrect or ‘don’t know’ answers are scored 0. A higher score

indicates greater accuracy.

2.3 Procedure
The study was approved by the Melbourne Health Research and Ethics Committee. After

complete description of the study procedures to participants, written informed consent was

obtained. Participants were first asked to complete the WASI and Digit Span. All other

measures were presented on a laptop computer, with the CESD-R completed first, followed

by the experimental measures. Permission was sought to audio record responses to Happé’s

Cartoon Task. The first author (ST) scored all the responses according to detailed scoring

criteria provided by Happé et al. (1999). Participants were reimbursed AU$30 and provided

with a debriefing statement upon completion.

3. Results
3.1 Demographic and clinical comparisons

Table 1 shows that there were no significant differences between the groups on age,

depressive symptoms, country of birth, living situation, and use of psychotropic medication.
Both groups faced similarly high levels of social disadvantage. Although there were no

differences between the groups on attention, the MDD group had a significantly higher full-

scale IQ score than the BPD group and a significantly higher proportion of students were in

the MDD group, whereas the BPD group had a higher proportion of individuals who were

employed.

Table 2 displays co-occurring diagnoses in both groups. In the BPD group, mood disorder

was the most commonly reported comorbidity, followed by an anxiety disorder. Almost 40%

of BPD participants also reported PTSD, compared with none in the MDD group; thus, post-

hoc analyses to explore the potential impact of PTSD diagnosis on ToM were conducted. A

majority of participants in each group were taking antidepressant medication (BPD: 73.2%,

MDD: 59.5%).

3.2 Comparisons between BPD and MDD on RMET

A mixed model ANCOVA was conducted, with valence as the within-participants factor,

group as the between-participants factor, and percent accuracy on the RMET as the

dependent measure. Participants’ age, intelligence, and depressive symptoms were retained as

covariates in the analysis. However, as recommended for repeated-measures ANCOVA (e.g.,

Annaz et al., 2009), because the within-participants main effects of emotion are independent

of the effects of between-participants covariates, such as depressive symptoms, the analysis

was first conducted excluding the covariates in order to examine pure within-participants

main effects. There was a significant main effect of valence, F(2, 75) = 34.61, p < 0.001,

partial ŋ² = 0.48. Bonferroni-corrected paired comparison tests demonstrated that, collapsed

across groups, accuracy was higher for negative stimuli (M = 76.79%, SE = 1.97) than for

both neutral (M = 64.71%, SE = 1.83) and positive (M = 63.39%, SE = 2.15) stimuli, ps <
0.001, but accuracy for positive stimuli did not differ from accuracy for neutral stimuli, p =

0.463.

After controlling for the between-participants effects of age, F(1, 73) = 6.10, p = 0.016,

partial ŋ² = 0.08, intelligence, F(1, 73) = 26.00, p < 0.001, partial ŋ² = 0.26, and depressive

symptoms, F(1, 73) = 0.31, p = 0.583, the main effect of group on accuracy was significant,

F(1, 73) = 4.36, p = 0.04, partial ŋ² = 0.06, but the interaction term (Group x Valence) was

not (p >0.05). As shown in Figure 1, the profile of accuracy for different valences was the

same for BPD and MDD. However, a significant group effect stemmed from overall greater

accuracy in the MDD group (MDD: M = 72.67%, SD = 12.97; BPD: M = 63.28%, SD =

15.22; Cohen’s d = 0.7).

3.3 Comparison between groups on Happé’s Cartoon Task

A mixed model ANCOVA was conducted, with cartoon type as the within-participants factor,

group as the between-participants factor, accuracy on the cartoons as the dependent measure,

and age, intelligence, and depressive symptoms as covariates. When the analysis was

conducted excluding the covariates to examine pure within-participants main effects, there

was no main effect of cartoon type, F(1, 76) = 3.67, p > 0.05, indicating that, collapsed

across groups, there was no group difference in accuracy on MS and PS cartoons.

After adjusting for the between-participants effects of age, F(1, 73) = 7.81, p = 0.007, partial

ŋ² = 0.10, intelligence, F(1, 73) = 26.70, p < 0.001, partial ŋ² = 0.27, and depressive

symptoms, F(1, 73) = 0.97, p = 0.329, partial ŋ² = 0.01, the main effect of group on accuracy

was not significant, F(1, 73) = 3.16, p > 0.05, partial ŋ² = 0.04, indicating that the BPD and

MDD groups did not differ in overall task accuracy when collapsed across cartoon type.
3.4 Effect of PTSD Diagnosis on ToM Findings

Given the high rate of PTSD among the BPD group (39%), post hoc independent samples t-

tests were conducted to explore the potential impact of PTSD diagnosis on ToM

performance. There were no significant differences between BPD participants with PTSD (n

= 16) and those without PTSD (n = 25) on affective ToM (RMET total accuracy: t(39) = -

0.55, p = 0.585), and cognitive ToM (MS cartoon accuracy: (t(39) = 0.29, p = 0.774).

Additionally, within the BPD group, no significant correlations were found between PTSD

diagnosis and affective and cognitive ToM (ps > 0.05).

4. Discussion
The major findings from this study of ToM in youth with first-presentation BPD are that the

BPD group demonstrated poorer performance for affective ToM only, compared with youth

with MDD, even after controlling for age, intelligence, and depressive symptoms.

The finding of reduced accuracy on the RMET in the BPD group is inconsistent with studies

comparing BPD samples with healthy controls that reported enhanced (Fertuck et al., 2009;

Frick et al., 2012) or comparable (Preiβler et al., 2010; Schilling et al., 2012) mental state

decoding, or a negative bias (Scott et al., 2011) in BPD. Similarly, the present finding

showing that responses of the BPD and MDD groups to MS cartoons were not significantly

different is in contrast to findings from Richman and Unoka (2015) indicating that overall,

adults with MDD less well than BPD participants on ToM tasks. In comparison to results

from studies using healthy control groups, the present findings are inconsistent with two

previous studies that found poorer performances on both cognitive and affective aspects of

ToM or empathy in adults with BPD (Dziobek et al., 2011; Preiβler et al., 2010). However,
the present findings are consistent with studies reporting intact (Ghiassi et al., 2010) or

superior cognitive ToM and mental state reasoning abilities in adults with BPD, compared to

healthy controls (Arntz et al., 2009; Franzen et al., 2011), and hypermentalising in

adolescents with BPD (Sharp et al., 2011, 2013). Also, the present study was unable to

replicate Harari et al.’s (2010) finding of dissociation between affective and cognitive ToM in

BPD.

This is the first study to examine ToM performance using the RMET and cartoons in a

sample of youth with recently diagnosed with either full-syndrome MDD or BPD with high

levels of co-occurring mental disorders (including mood disorder and PTSD), and minimal

exposure to mental health treatment. Therefore, discrepant findings might be attributable to

sample differences in terms of age, severity of disorder and/or duration of illness, and level of

other psychopathology. Previous ToM studies have largely utilised adult samples, with few

exceptions (Scott et al., 2011; Sharp et al., 2011; 2013). Compared with adult participants in

previous RMET studies, the youth in our sample were almost 10 years younger. Further,

Scott et al.’s (2011) non-clinical sample of university students, while of almost identical age

to the present sample, had much lesser severity of BPD features. Although Sharp et al. (2011)

also used a sample of youth, this group comprised inpatients with a mixture of sub-syndromal

and full syndrome BPD, and high comorbidity with MDD. The potential confounding

influence of IQ and depression was not taken into account in that study. Youth in the current

study appear to be at the more severe end of the BPD severity spectrum in terms of number of

BPD features, intelligence, level of social disadvantage, and co-occuring mental disorder.

Thus, symptom severity might have adversely affected ToM performance.

Some previous RMET investigations of adult individuals with BPD compared to healthy
controls, such as Fertuck et al.’s (2009) better performing sample, are also likely to have had

longer duration of illness. It is possible then that enhanced RMET in the latter sample might

be due to maturational effects, to hypervigilance to social stimuli that might develop

secondary to the recurrent experiences in interpersonal relationships and with individuals in

the mental health system or to lower levels of co-occuring disorders. Hence, enhanced mental

state decoding might develop later in the course of the disorder and represent an adaptive

attempt to gain control over social environments compromised by severity of BPD features,

cumulative trauma, and recurrent mental state disorders (Chanen et al., 2008).

4.1 Theoretical Implications

The present findings are consistent with some aspects of mentalisation theory and discrepant

with others. The demonstration of poorer performance on an affective ToM task in a sample

of youth is consistent with the developmental focus of mentalisation theory (Fonagy and

Luyten, 2009), which asserts that understanding others’ behaviour in terms of mental states is

a developmental achievement. Indeed, brain maturation during adolescence has been

associated with more developed social-cognitive processes, such as, response inhibition,

emotion regulation, the capacity to meta-monitor, and the capacity for abstract and

hypothetical thought (Nelson et al., 2005; Paus, 2005). As such, it is possible that a

developmental failure or delay in acquiring affective ToM, is an important contributing factor

in the development of clinically significant borderline pathology during adolescence

(Jennings et al., 2012).

The finding of reduced affective ToM in the RMET performance of the BPD participants

relative to the MDD group, however, is inconsistent with the proposition that social cognition

in BPD might be more impression-driven due to a lack of counterbalancing of the implicit,

automatic, non-conscious, immediate form of social cognition by the explicit-controlled,

conscious, reflective mode of mentalising (Fonagy and Luyten, 2009; Sharp et al., 2013).

However, it is important to note that there are differing interpretations of what the RMET

claims to measure. While the RMET has been described as involving the unconscious, rapid,

and automatic decoding of mental states, without cognitive deduction of mental content

(Baron-Cohen et al., 2001), it has also been suggested that it taps explicit-controlled

mentalising, as it seems to call on the individual to read mental states from external cues, and

a decontextualised display of the eye region of the face (Sharp et al., 2013). It is possible that

the RMET might be more closely related to cognitive ToM, rather than affective ToM, as it

has been argued to place greater emphasis on the detection and attribution of beliefs and

intentions than on emotions (Baron-Cohen et al., 2001; Legg, 2012).

4.2 Limitations

An important methodological limitation is the absence of a healthy control group, in addition

to the two clinical groups, as this may have enabled more informed interpretation of the

meaning of differences found in level and patterns of responses by the BPD and MDD

groups, and more direct comparisons with the majority of previous studies. However, we

argue that there are issues about what constitutes a healthy control group in the context of the

current study. Identifying putative healthy control (non-psychiatric) members who are

equivalent in age may mean be that they differ in terms of other characteristics, e.g.,

education level, occupation, and so on. They will differ also into how they are selected into

such a study. Attempting to match participants is always difficult and may lead to the

“matching fallacy” (Meehl, 1970; Snitz, MacDonald, and Carter, 2006; see Kremen et al.

1996 for an illustrative empirical example). Given the ubiquity of mood disorder in early as

well as later presentations of BPD and the value in clinical terms of differentiating the
contributions of the two disorders to TOM difficulties early in the course of BPD, we argue

that comparison of BPD and MDD using acutely unwell participants provides a compelling

test, as differences between healthy controls and BPD participants could be attributed to the

BPD participants having nonspecific pathology.

A second major limitation relates to the ecological validity of the ToM measures, which

involved passive observation and interpretation of others’ interactions through pictures (‘cold

cognition’). Although the present study demonstrated that deficits in ToM in youth with BPD

are not limited to contexts involving themes of potential emotional significance or underlying

schemas, it has been argued that disturbances in social cognition might become more

apparent when the individual is personally invested in an interaction, and when that

interaction is emotionally-charged (‘hot cognition’, Arntz and ten Haaf, 2012; Fonagy and

Luyten, 2009; Sharp et al., 2013; Andreou et al., 2015). Indeed, Sharp et al. (2013)

emphasised that tests like the MASC, which are more closely related to interpersonal

functioning rather than pure cognitive mentalising, might be more likely to trigger

dysfunctional internal working models of attachment relationships (Bretherton and

Munholland, 2008), along with hyperactive emotional responsivity, giving rise to anomalous

mentalising in BPD patients . Available findings from studies using the MASC showing

evidence of hypermentalising provide some support for this assertion (e.g., Andreou et al.,

2015: Sharp et al., 2013; Vaskinn et al., 2015) .The ToM measures used in the present study

are relatively emotionally neutral compared with the MASC. Furthermore, they were not

designed to be able to detect hypermentalising; responses on the RMET and Cartoon Task

simply reflect either accurate or inaccurate ToM, and do not indicate whether incorrect

responses are due to over-interpretation. Therefore, it would be desirable for future studies to
assess social cognition using more naturalistic paradigms, in more interpersonal, BPD-

specific situations, or under high stress (Arntz et al., 2009).

Another potential limitation relates to the lack of assessment of other potential confounding

factors, such as externalising problems and childhood maltreatment. Given the high

comorbidity between BPD and externalising problems, and an association between social-

cognitive deficits and externalising (Sharp, 2008), investigation of whether ToM impairments

are driven by externalising pathology more broadly is needed. Childhood maltreatment has

also been known to be a factor that potentially influences social perception (Preiler et al.,

2010; Scott et al., 2011). However, we note that the higher levels of PTSD in our BPD

participants appear not to have influenced outcomes for that group.

Finally, the lack of inter-rater reliability on Happé’s Cartoon Task and the use of clinical

diagnoses for co-occurring syndromes in the MDD group also represent limitations. Other

sample-related limitations include only studying females. It remains unclear how present the

findings might relate to males with BPD.

Despite these limitations, a significant strength of this study is its investigation of ToM

abilities in a novel sample of acutely unwell community-treated youth with first-presentation

BPD, minimising duration of illness factors. Also, the use of a clinical control group of youth

with MDD drawn from the same public sector setting, along with measurement of depressive

symptoms in both samples, allowed investigation of the specificity of current findings to

BPD.We note that the majority of the extant research has investigated ToM in adults across a

range of diagnostic groups in comparison to healthy controls. For the most part this research

shows that, across age groups, mental and personality disorder diagnosis and severity of
pathology influence performance on social cognition tasks differentially (e.g., Andreou et al.,

2015; Lee et al., 2005; Semerai et al., 2014, 2015; Unoka et al, 2014; Wang et al 2008;

Vaskinn et al., 2015). We believe the present study investigating two clinical samples

comprised of at risk, symptomatic youth presenting early in the course of illness makes a

contribution to the literature and is likely to be of value to researcher and clinicians.

Importantly, the finding that, with depressive symptoms controlled for, youth early in the

course of BPD had less accurate affective ToM, underscores the importance of early

intervention. Specifically, it reinforces the notion that mentalising might be a valuable target

for treatment, which is consistent with existing treatment programs that focus on helping

individuals to develop these abilities (Chanen and Thompson, 2014).

In summary, the present study provides evidence very early in the course of BPD, of reduced

performance on measures of both affective and cognitive ToM, relative to youth with MDD.

These findings are consistent with a developmental failure of socio-cognitive abilities needed

for mentalisation, which might give rise to core features of BPD (Fonagy and Luyten, 2009;

Ryle, 1997). Longitudinal research is needed to investigate developmental aspects of social

cognition in BPD using more naturalistic paradigms that also allow investigation of the

contribution of other psychopathology to ToM functioning.

Acknowledgements

We would like to thank Drs Jennifer Betts and Christopher Davey for their support in the

recruitment of participants and Drs Jean Cheng and Kate Caldwell for their assistance with

data collection. We are indebted to Professor Simon Baron-Cohen and Professor Francesca

Happé for providing the Reading the Mind in the Eyes Test and the Cartoon Task

respectively.
Declaration of Interest

The authors declare that there is no conflict of interest. This research received no specific
grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Figure 1: Mean percent task accuracy in BPD (n = 41) compared to MDD groups (n = 37)
for RMET. Error bars indicate standard error of the mean.

Table 1: Demographic Characteristics for BPD and MDD Groups

BPD (n = 41) MDD (n = 37)
M (SD) M (SD) t p-value
Age (years) 18.44 (2.71) 18.59 (2.58) 0.26 0.79
WASI full-scale IQ 95.66 (18.08) 103.30 (13.17) 2.15 0.04*
Digit Span 9.90 (2.47) 9.30 (2.07) -1.17 0.25
CESD-R 43.00 (17.15) 38.59 (18.03) -1.11 0.27

n (%) n (%) 2 p-value

Accommodation
Alone 2 (4.9) 0 (0)
Family/partner/friends 39 (95.1) 34 (91.9)
Other 0 (0) 3 (8.1) 5.15 0.08
Australian/New Zealand born 37 (90.2) 33 (89.2%) 0.02 0.88
Employment
Student 6 (14.6) 26 (70.3)
Employed 28 (68.3) 5 (13.5)
Unemployed 7 (17.1) 6 (16.2) 28.48 0.00**
Education
Lower Secondary 27 (65.9) 12 (32.4)
Upper Secondary 12 (29.3) 20 (54.1)
Tertiary 2 (4.9) 5 (13.5) 8.87 0.01*
Social disadvantage
High 20 (48.8) 18 (48.6)
Medium 17 (41.5) 14 (37.8)
Low 4 (9.8) 5 (13.5) 0.30 0.86
Psychotropic medication use 32 (78.0) 22 (59.5) 2.34 0.13
Notes:
*p < 0.05
**p < 0.01; BPD = Borderline Personality Disorder; CESD-R = CESD-R = Centre for Epidemiologic
Studies Depression Scale – Revised; IQ = Intelligence Quotient; MDD = Major Depressive Disorder.

Table 2: Co-occurring Diagnoses in the Clinical Groups

BPD (n = 41) MDD (n = 37)
Current Psychiatric Disorders, n (%)
Mood disorder 35 (85.4) 37 (100.0)
Anxiety disorder 26 (63.4) 12 (32.4)
PTSD 16 (39.0) 0 (0)
Other Axis I disorder 7 (17.1) 2 (5.4)
Other non-BPD Axis II disorder 18 (43.9) 0 (0)

Notes: BPD = Borderline Personality Disorder; MDD = Major Depressive Disorder; PTSD =
Post-Traumatic Stress Disorder
Highlights
 Youth with BPD or depression completed cognitive and affective ToM tasks

 BPD group performed significantly worse than the MDD group on both ToM tasks

 Findings were maintained even after controlling for age, intelligence and depressive

symptoms

 Results suggest a developmental basis for social impairments seen in BPD