EDITORIAL
Hypermentalization in Adolescents With
Borderline Personality Traits: Extending the
Conceptual Framework to Younger Ages
Marianne Goodman,
S
hould borderline personality disorder (BPD)
be diagnosed in adolescence? This is a con-
troversial question because adolescent-onset
BPD is difficult to differentiate from the moodiness
and relationship turmoil of normal adolescence.
Moreover, there exists a lack of stability of the BPD
diagnosis in adolescent inpatient populations and
community samples. However, countering these
concerns is a growing consensus pertaining to the
existence of adolescent-onset BPD and its negative
consequences on facets of adult and adolescent
functioning.1 Miller et al.2 suggested two possible
subgroups of adolescents with BPD: one with more
severe symptomatology, in whom the diagnosis
persists; and another with less severe symptom-
atology, in whom symptom profiles vacillate and
the diagnosis does not persist. One survey of
parental reports has clearly indicated that there
are distinct patterns of dysfunction above and
beyond “normal” adolescence, that offspring
who develop BPD have a completely distinct
adolescence from their siblings without BPD,
and that adolescent manifestations of the full
disorder are common.3
BPD is hypothesized to include disordered
mentalization, and therapies that target this def-
icit may be helpful. In this issue of the Journal,
Sharp et al.4 examine mentalization in adoles-
cents with borderline traits. Mentalization and
theory of mind (TOM) are overlapping con-
structs; however, TOM is a narrower concept
pertaining to the cognitive development of men-
talizing capacities. Although philosophical de-
bate about TOM dates back to the time of Des-
cartes, mentalization entered psychoanalytic
circles approximately 50 years ago. Mentaliza-
tion, defined as a “form of imaginative mental
activity, which allow us to perceive and interpret
human behavior in terms of intentional mental
536 www.jaacap.org
M.D., AND Larry J. Siever, M.D.
states (e.g., needs, desires, feelings, beliefs, goals,
purposes, and reasons,”5 has been described us-
ing multiple dimensions including implicit ver-
sus explicit thinking, self versus other, cognitive
versus affective, and internal versus external
poles.6 These mentalization dimensions have dis-
tinct neurobiological underpinnings, including
involvement of different brain regions. For in-
stance, imaging studies have implicated older
brain regions including the amygdala, basal gan-
glia, ventral medial prefrontal cortex and dorsal
anterior cingulate cortex in implicit thinking,
whereas the explicit system relies on newer brain
circuits including the rostral anterior cingulate
cortex, medial and lateral prefrontal and parietal
cortices, and medial temporal lobe.6 Mirror neu-
rons, initially discovered in rhesus monkeys by
Giacomo Rizzolatti, a neuroscientist at the Uni-
versity of Parma, fire when an animal acts and
when the animal observes the same action per-
formed by another. This mirroring action is hy-
pothesized to be the physiologic basis underlying
understanding intentions, imitation, TOM, and
empathy.7
Mentalization has been extended into a frame-
work and treatment paradigm for BPD by incorpo-
rating a developmental model and attachment the-
ory. Specifically, Fonagy and Bateman8 postulated
an interaction of constitutional factors in the infant
with traumatic backgrounds best described as en-
vironments steeped in parental under-involvement
or neglect leading to deficits in the child’s ability to
regulate emotions. Subsequent traumatic events or
maltreatment (or the “invalidating environment”
of Linehan9) create disturbed attachment styles that
are easily activated in individuals with BPD. The
heightened arousal of interpersonal situations that
trigger the attachment system overwhelms health-
ier mentalization processes.
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 50 NUMBER 6 JUNE 2011

Supporting earlier work by the same group (led
by Peter Fonagy), the article by Sharp et al.4 studies
the relation of mentalization to borderline traits in
adolescents using a TOM assessment, the Movie for
the Assessment of Social Cognition, a 15-minute film
about four individuals attending a dinner party
that is stopped at 45 points to ask questions
about their feelings, thoughts, and intentions.
Adolescents with BPD traits were found to
hypermentalize, defined as “over-interpreta-
tive mental state reasoning.” This over-interpre-
tation or over-attribution of intentions or mental
states to others is suggestive of the implicit and
affective-based mentalization pattern that is depen-
dent on phylogenetically older neural pathways. A
logical next step in this line of inquiry would be to
document this pattern with brain imaging studies
of critical affect regulatory regions, including the
amygdala and the insula.
The concept of mentalization in psychiatric dis-
orders is important because abnormalities manifest
across a spectrum that ranges from deficient men-
talization in autism to exaggerated or distorted
attributions in BPD. This article highlights the mer-
its of studying younger populations of individuals
with BPD and BPD traits, which may lead to a
more thorough characterization of the illness in
younger cohorts. Establishing the overlap and dif-
ferences with adult-onset BPD is an important next
step, as is clarifying the relation between hyper-
mentalization and the severe mood dysregulation
seen in many adolescents.10 This syndrome in
youth has been attributed to bipolar disorder or
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JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 50 NUMBER 6 JUNE 2011
EDITORIAL
attention-deficit/hyperactivity disorder but may in
some instances represent a precursor to BPD. Over
time, this type of research may address the current
bias against identifying, diagnosing, and develop-
ing clinical interventions specific for adolescent-
onset BPD.
Treatment implications from this work sug-
gest that therapies that help patients develop
mentalization capabilities might prove beneficial,
particularly in situations where interpersonal
conflict has arisen. Such interventions include the
mentalization treatments described by Bateman
and Fonagy11 and skills training focusing on
mindfulness, perspective taking, and interper-
sonal effectiveness taught in dialectical behav-
ioral therapy9 targeted for adults and adolescent
populations. Future treatment research should
use social cognition paradigms such as those
employed in the article by Sharp et al. to assess
TOM and mentalization with imaging before and
after treatment. &
Accepted February 24, 2011
Drs. Goodman and Siever are with James J. Peters Veterans Affairs
Medical Center, Mount Sinai School of Medicine.
Disclosure: Drs. Goodman and Siever report no biomedical financial
interests or potential conflicts of interest.
Correspondence to Marianne Goodman, M.D., James J. Peters
Veterans Affairs Medical Center, 130 West Kingsbridge Road,
Bronx, New York 10468; e-mail: Marianne.Goodman@va.gov
0890-8567/$36.00/©2011 American Academy of Child and
Adolescent Psychiatry
DOI: 10.1016/j.jaac.2011.02.013
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