The Borderline Empathy Paradox: A Review of Empathic ...



The Borderline Empathy Paradox: A Review of Empathic Enhancement in Borderline Personality Disorder

J. Pers. Disorders (in press, July 2012)

The Borderline Empathy Paradox: Evidence and Conceptual Models for Empathic Enhancements in Borderline Personality Disorder

Natalie Dinsdale and Bernard Crespi

Natalie L. Dinsdale & Bernard J. Crespi

Department of Biological Sciences

Simon Fraser University

Abstract:

Empirical evidence and descriptions of therapeutic interactionstherapeutic interactions have pointed toward possiblesuggested that individuals with borderline personality disorder (BPD) may demonstrate enhancements in aspects of social- emotional cognition among individuals with borderline personality disorder (BPD). Given the severe interpersonal impairments that characterize this condition, evidence for superior empathic skills - 'borderline empathy' - in individuals with BPD has remained puzzling. To determine if this phenomenon exhibits empirical validity existassess the empirical evidence for this phenomenon, and to comprehensively understand evaluate alternative hypotheses for its possible role in BPD etiology and symptoms, we systematically searched the literature for investigations of empathy in BPD and reviewed 27 studies assessing a range of empathic abilities. Considered together, these data demonstrated comparable levels of evidence for enhanced, preserved and reduced empathic skills in individuals with BPD. , Esuch that evidence for empathic enhancements ins thus substantial but inconsistent across studiest across studies, being found mainly under socially-interactive experimental paradigms.. Notably, all three studies using socially-interactive paradigms to assess aspects of empathy indicated enhancements in BPD, suggesting that ecological validity of empathic tasks may be important in the detection ofdetecting enhancements. Based on the results of the review, and previous explanations for BPD symptoms, Drawing from the reviewed evidence and previous theories, we wWe propose a new model for explaining the borderline paradox: that a combination of increased attention to social stimuli withaandwithnd dysfunctional social-cognitive information processing may account in part for the paradoxical nature of specific empathic enhancements and reduced overall social functioning in BPD.

Introduction This model for explaining the 'borderline paradox' is directly analogous to explanations for enhanced systemizing skills in autism spectrum conditions that implicate increased attention to, and superior perception of, non-social stimuli. Future research on 'borderline empathy' might usefully focus on further tests that involve socially-interactive stimuli, evaluation of the attention/processing model, and consideration of the possibility that over-development of specific social brain adaptations may be pathological and mediate the expression and phenotypes of some psychiatric conditions.

Introduction

Clinical anecdotes and recent empirical evidence have suggested that individuals with borderline personality disorder (BPD) may demonstrate enhanced empathy in spite of impaired interpersonal functioning, a paradox referred to as 'borderline empathy' (Krohn, 1974; Franzen et al., 2011). Drawing from therapeutic interactions with borderline patients, the psychoanalyst Alan Krohn (1974) first identified the paradoxical nature of the diagnosis, describing how some individuals with BPD appear to possess an uncanny sensitivity to other people's subconscious mental content and mental states, despite their inability to coherently integrate such information into stable concepts of self and other that are fundamental to healthy interpersonal functioning. Both Krohn (1974) and Carter & Rinsley (1977) proposed that enhanced empathic sensitivity develops in the borderline child in response to confusing or neglectful parenting, which motivates the child towards increased empathic functioning.

Aside from the models based on Krohn (1974), there have been few attempts to explain the causes underlying borderline empathy or its role in BPD etiology and symptoms. This general lack of study may be attributable in part to the questions of whether or not the phenomenon actually exists, and further, if it can be clearly and reliably documented and explained. Recent studies have reported both enhanced (ie. Franzen et al., 2010; Fertuck et al., 2009) and impaired (ie. Preißler et al., 2010) social cognition in BPD, but the evidence for borderline empathy has yet to be comprehensively reviewed and evaluated in the context of alternative hypotheses for causation.. In this paper we evaluate the existing evidence for enhanced empathy in BPD, through systematically searching the literature and providing an overview of the relevant studies with consideration of their varying methodological approaches. We conclude by synthesizeing these findings in the context of current theories that address the roles of empathy in psychiatric illness, develop a new, testable hypothesis based on increased attention to social stimuli, and and finally, by suggesting novel directions for future research in BPD based on our findings and model..

Borderline personality disorder

Borderline personality disorder (BPD) is characterized by emotional dysregulation, impulsive behaviourbehavior, high levels of sensitivity to the social environment, pervasive instability in mood, behaviourbehavior, self identity and interpersonal relationships, and a tendency toward black-or-white thinking (Gunderson, 1984, 2009; Crowell et al., 2009; Fonagy & Luyten, 2009; Fonagy et al. 2011). Individuals diagnosed with BPD experience chaotic interpersonal relationships, fear of rejection, and elevated rates of self-injury and suicide;. tThe severely debilitating nature of BPD combined with its estimated lifetime prevalence ranging from 1 - 5.9% have spurredmotivated recent empirical investigations into its etiology (Torgersen et al., 2001; Grant et al., 2008; Gunderson, 2009; Paris, 2010). Current causal accounts of BPD implicate the interaction of predisposing biological vulnerabilities with dysfunctional childhood environments (Arens & Barnow, 2011).

The term 'borderline' was originally introduced in a psychoanalytic context to describe individuals that presented with symptoms at the 'border' of neurosis and psychosis (Stern, 1938). As this diagnostic category has evolved, BPD has often been conceptualized as primarily an affective disorder, evidenced by its high comorbidity with several Axis 1 disorders on the affective spectrum, including major depression (41-83%), and bipolar disorder (10-20%), post-traumatic stress disorder (46-56%), and panic disorders (31-48%) (reviewed in Lieb et al., 2004). HoweverAdditionallyHowever, a substantial proportion of individuals with BPD experience stress-induced psychotic symptoms, and some BPD patients develop more severe, long-term psychoses (Barnow et al., 2010; Glaser et al., 2010; Pope et al., 1985). Given the heterogeneity in borderline symptoms, debate remains as to how BPD is most accurately demarcated from other Axis 1 and Axis II disorders, though it clearly overlaps in its symptoms and comorbidities with both the psychotic and affective spectrums of psychiatric illness (Perugi et al., 2011).

Considering the difficulties that individuals with BPD have in developing enduring social relationships, several lines of research and therapeutic models have proposed that deficits in mentalizing abilities- the ability to perceive infer thoughts and intentions and interpret the the behaviour of others - play a key role in borderline symptoms and etiology (Bateman & Fonagy, 2003; Choi-Kain & Gunderson, 2008; Fonagey & Luyten, 2009). Mentalization, or in a broader sense, empathy, comprises a broad suite of inter-rrelated social and emotional skills, and the nature of alterations to these abilities in borderline populations has yet to be clearly elucidatedunderstood.

Empathy, esdescribas defined here, can be defined asis the capacity to perceive, experience and share emotional states of others, as well as the ability to understand their mental perspectives (Choi-Kain & Gunderson 2008; Davis, 1983; Duan & Hill, 1996; Preston & de Waal, 2002). Most broadly, empathy can be considered to involve a range of socio-cognitive processes including affective resonance, imitation, perspective taking, and sympathy, that together facilitate complex, dynamic social interactions. Theoretical, neurological, and behaviourbehavioral evidence supports a distinction between different facets of empathic skills, particularly the affective and cognitive components (Gallup, 1979; Rankin et al., 2005; Smith, 2006; Singer, 2006). Thus, aAffective (emotional) empathy describes the sharing of, or identification or sharing with,of an emotional state of another individual, whilewhereas cognitive empathy involves the ability to infer another person's thoughts, feelings orand intentions. Cognitive empathy is essentially equivalent to Theory of Mind (ToM) and mentalizing in that these terms all describe the ability to make inference or attributions about the mental states of others (Premack & Woodruff, 1978; Davis, 1996; Frith & Frith, 2003; Decety & Moriguchi, 2007). For the purposes of this articlereview, the term empathy refers to a range of social skills that includes both emotional and cognitive components. It is important to distinguish this definition of empathy and empathic skills from conceptualizations of

empathy as positive social-emotional mental connections that foster cooperation, altruism, and well-being of the recipient (e. g., Baron-Cohen 2011).

Through synthesizing the existing empirical evidence assessing empathic skills in individuals with BPD, we address the question of the degree to which individuals diagnosed with this condition exhibit evidence for enhanced empathy. We also consider evaluate alternative hypotheses for helping to explain the ‘borderline empathy paradox’, in the context of specialized, enhanced skills in other psychiatric conditions, especially autism, and develop a new model to help explain enhanced empathy in BPD..

Methods

Literature was systematically reviewed using the online databases Web of Science and PubMed. For the purposes of this article, the term ‘empathy’ refers to a range of skills that includes both emotional and cognitive components (Gallup, 1979; Rankin et al., 2005; Smith, 2006; Singer, 2006). It is important to distinguish this definition of empathy and empathic skills from conceptualizations of empathy as positive social-emotional mental connections that foster cooperation, altruism, and well-being of the recipient (e. g., Baron-Cohen 2011). Given the numerous definitions for describing empathizing and mentalizing in the literature, several search terms were used to ensure that all studies examining any domain of empathic skill were included. The following terms were chosen a priori and were searched in conjunction with “borderline personality disorder”: empathy; theory of mind; mentalizing; borderline empathy; and emotion recognition. All references and citing articles from the selected studies were reviewed to check for additional relevant articles. For inclusion, articles needed to empirically assess a domain ofn interpersonal empathic skill (e. g., facial emotion recognition, mental state attribution, using the definition of empathy described above) or self-reported empathy in a borderline population compared to appropriate controls, or as a function of borderline features in a non-clinical sample. Because affective instability is a diagnostic criterion for BPD (APA, 2000), articles that only assessed affective regulation skills were excluded as all individuals with a borderline diagnosis have reduced functioning in these areas. (APA, 2000). Only peer-reviewed empirical studies were included; reviews, supplementary materials, and meeting abstracts were not.

Results

The literature search yielded 130 articles, of which 27 met the criteria for inclusion. These articles assessed various aspects of empathy and were organized into categories based on a combined consideration of the ability under study and the accompanying methodological approach. The six categories included: (1) nonverbal sensitivity; (2) emotion recognition; (3) self-reported empathic skills; (4) emotional intelligence; (5) inferring mental states from passive stimuli such as photographs, movies, cartoons, and stories; and (6) mentalizing in interactions with active stimuli. One study (Harari et al., 2010) investigated both self-reported empathic skills and mental state attribution from stimuli and was therefore included in both categories.

Table 1 summarizes the articles in each empathic domaincategory and the number of findings reporting enhanced, reduced, or comparable performance of borderline individuals relative to controls. Overall, the 27 studies employed 19 different socio-empathic tests and reported 40 relevant findings: 13 reported enhanced skills; 13 reported reduced skills; and 14 reported similar skills. Evaluating the patterns and causes of variation among studies of empathy in BPD requires consideration of the procedures deployed and their findings, in each domaincategory.

(1) Nonverbal sensitivity

In the first study to explicitly investigate the borderline empathy phenomenon, Frank and Hoffman (1986) used the Profile of Nonverbal Sensitivity (PONS: Depaulo & Rosenthal, 1979) in a sample of 10 female borderline patients and 14 sex-- and education-matched neurotic control subjects and reported that individuals with BPD demonstrated a heightened sensitivity to nonverbal cues relative to the clinical controls in the study.

(2) Emotion recognition

Emotion recognition has received the most empirical attention of all empathic skills in borderline populations. Based on a review of six of the 12 studies listed above, Domes et al. (2009) concluded that individuals diagnosed with BPD demonstrate subtle impairments in basic emotion recognition, a heightened sensitivity to detecting negative emotions, and a negativity bias when appraising ambiguous stimuli. Five of these six studies used similar facial stimuli (Pictures of Facial Affect; Ekman & Friesen 1976, 1979, 1993), so while the results may be reliable, they may not be generalizable to studies employing more realistic stimuli.studies that employ tasks and stimuli more closely resembling realistic social interactions.

Dyck et al. (2009) assessed facial emotion recognition abilities in 19 borderline personality patients (17 females) with and without comorbid post-traumatic stress disorder and in sex-matched healthy controls using two different tasks with coloured facial stimuli (from Gur et al., 2002). The Fear Anger Neutral (FAN) test asks subjects to rapidly discriminate between negative and neutral facial expressions and the Emotion Recognition (ER) test involves the precise identification of an emotion out of five possibilities (sadness, happiness, anger, fear and neutral) with no time limits. When time was constrained, borderline subjects performed poorermore poorly than did the control group, misinterpreting neutral faces as negative significantly more often. In the absence of time limits, the borderline subjects performed equally well as the controls, suggesting that individuals with BPD may process complexly integrated emotional stimuli more slowly than healthy controls; a similar conclusion was supported in Minzenberg et al. (2006; reviewed in Domes et al., 2009).

Guitart-Masip et al. (2009) compared the emotion discrimination abilities of ten individualspatients with BPD (five females) and ten non-clinical sex-matched controls by presenting pairs of neutral and emotional faces (happiness, fear, disgust, anger) from the Ekman and Friesen (1979) series. Stimuli were presented for 700 ms and subjects were instructed to press a button corresponding to the emotional face. Patients demonstrated a reduced performance relative to controls when identifying fear and disgust but performed equally well as control subjects for happy and angry faces. Similarly, Unoka et al. (2011) investigated patterns of accuracy and error in emotion recognition using the Ekman 60 Faces test in 33 BPD inpatients (29 female) and 32 (30 females) matched healthy controls; BPD subjects individuals did not demonstrate impairments in recognizing happy emotions, but did show reduced accuracy in discriminating negative emotions as well as a tendency to over-attribute surprise and disgust and under-attribute fear, relative to the control subjects. Conversely, in a sample of 11 females with BPD and nine non-clinical female controls, Merkl et al. (2010) assessed facial expression recognition using Ekman and Friesen's (1993) stimuli set and reported superior performance of borderline subjects in identifying fear.

Two of the articles investigating emotion recognition studied the relationship of these skills to borderline personality features in non-clinical populations; this kind of sampling method is particularly useful in revealing the skills and deficits associated with a borderline personality profile in the absence of significant interpersonal impairment. In a sample of 150 adults sampled from university students and the wider community (70% female), Gardner et al. (2010) reported a significant interaction between borderline features and executive control with respect to decoding angry facial expressions, such that high borderline features combined with low executive control predicted poor recognition of angry faces while high borderline features and high executive control predicted enhanced recognition of angry faces. Executive control describes the ability to regulate attentional resources and is often impaired in psychiatric patients, including individuals with a BPD diagnosis (Ayduck et al., 2008). The interaction of borderline features with decreased attentional resources may thus be responsible for mediating deficits in emotion recognition in BPD.

(3) Self-reported empathy

Two studies examined self-reported empathy in individuals with BPD using the Interpersonal Reactivity Index (IRI, Davis, 1980; 1983). Employed extensively in personality research, the IRI is a multidimensional self-report measure of empathy assessing the related but dissociable cognitive and affective components of empathic skill across four subscales: perspective taking; fantasy; empathic concern; and personal distress. Using this instrument, Guttman and Laporte (2000) reported reduced cognitive empathy and increased affective empathy in 27 females with borderlineBPD subjects relative to clinical and non-clinical controls subjects. In a sample of 20 individuals with BPD (18 females), Harari et al. (2010) found significantly reduced cognitive empathy in individuals with BPD relative to non-clinical controls but comparable levels of affective empathy.

(4) Emotional intelligence

Four studies have measured emotional or personal intelligence in BPD; in these studies, the definitions of personal and emotional intelligence describe essentially identical skills. For example, emotional intelligence describes the capacity to perceive, understand, and regulate emotion in addition to using emotions to facilitate mental processes (Mayer & Salovey, 1997). Personal intelligence involves the ability to access one's emotions as well as the ability to perceive and distinguish among another person's motivations and intentions (Gardner, 1983).

Prompted by clinical accounts of the borderline empathy paradox, Park et al. (1992) hypothesized that borderline individuals are endowed with enhanced personal intelligence that could interact with abusive childhood environments to play a key causal role in the development of BPD. To test this idea, the authors evaluated the personal intelligence and history of past abuse of 23 borderline patients (18 females) from their own clinical work and 38 outpatients with other personality disorder diagnoses. For the purpose of this study, Park et al. (1992) derived a rough scale of personal intelligence from Gardner's (1983) research. SubjectsPatients were categorized as 'gifted' in the domain of personal intelligence if they clearly demonstrated at least three of the following: (1) intense preoccupation with and/or access to feelings of self and others; (2) at least three perceptive observations about other people as expressed during therapy sessions; (3) evidence of empathic concern; and (4) and the absence of pervasive envy, grandiosity or devaluation of others. Preoccupation with feelings was included because the authors reasoned that if individuals with BPD are indeed endowed with emotional giftedness, but these abilities are not realized due to poor environments, the giftedness may manifest as a drive to access and understand emotions. The authors reported that 74% of the borderline patients demonstrated both enhanced personal intelligence and a history of abuse, significantly greater than the 13% of the non-borderline controls. Though intriguing, these results must be interpreted cautiously due to the lack of independent validation for their method of assessing personal intelligence, and the potential for clinician bias.

Beblo et al. (2010) studiedassessed emotional intelligence in a sample of 19 borderline patients (16 females) and 20 non-clinical controls subjects (17 females) using the Mayer-Salovey-Caruso emotional intelligence test (MSCEIT; Mayer et al., 2002) and the Test of Emotional Intelligence (TEMINT; Schmidt-Atzert & Buehner, 2002). These tests assess performance in four domains of emotional intelligence (perceiving, understanding, and regulating emotion, and applying emotions to mental processes) across a variety of tasks. No difference between BPD subjectsindividuals and control subjects was found for any domain of emotional intelligence. . Using only the MSCEIT, Hertel et al. (2009) assessed emotional intelligence performance in 19 female borderline subjectspatients as well as other clinical and non-clinical samplesindividuals and reported a reduced overall emotional intelligence score of the borderline group relative to the non-clinical control group. Specifically, the borderline patients were reduced in their ability to understand emotional information and to regulate emotions but they performed equally well as the non-clinical controls in perceiving emotions and using emotions to facilitate thought. In contrast to Beblo et al.(2010), Hertel et al. (2009) did not control for general intelligence and therefore the reduced emotional intelligence performance of the BPD patients may be attributable to group differences in cognitive ability. Variation in borderline symptom severity may also differentially affect emotional intelligence ability in these two studies, but there is insufficient data to evaluate this claim.

In a non-clinical sample of 523 adults (78% female), Gardner & Qualter (2009) studied the relationship of borderline personality features to both trait and ability emotional intelligence using the Schutte Emotional Intelligence Scale (SEIS; Schutte et al., 1998) and the MSCEIT, respectively. Most of the assessed borderline personality features negatively predicted MSCEIT scores for the abilities of understanding, managing, and facilitating emotions. The ability to perceive emotions was not related to BPD features. Overall SEIS score, which measures the trait-based ability to manage, perceive, and utilize emotions were negatively related to borderline features.

(5) Mentalization using passive stimuli

Given the recent interest in mentalization-based approaches to treating BPD (Fonagey & Luyten, 2009) and the availability of instruments from autism research for assessing theory of mind skills, recent work has begun to assess 'mindreading' skills in borderline populations. Results from these five studies are mixed. For example, using Happé's Advanced Theory of Mind Test, Arntz et al. (2009) assessed mentalizing skills in 16 female patients with BPD, 16 female patients with cluster-C personality disorder diagnoses, and 28 female non-clinical control subjects; study participants were matched for both age and intelligence. TheThe test was translated into Dutch for the purpose of this study and included stories involving white lies, persuasion, bluffs and mistakes in addition to non-mental stories for control purposes. After hearing the stories, subjectsindividuals are asked questions about the character's mental states. IndividualsPatients with BPD performed significantly better than the healthy controls, though cluster-C patients had the highest scores overall.

In another study, Ghiassi et al. (2010) studied mentalizing and parent rearing behaviourbehavior in 50 borderline patients (46 womenfemales) and 20 non-clinical control subjects (13 women females) using two mental state attribution tasks that have been employed in psychoses research; the Mental State Attribution Task- Sequencing and the Mental State Attribution Task- Questionnaire (MSAT-S & MSAT-Q; Brüne, 2005). SubjectsIndividuals are asked to logically sequence a variety of cartoon pictures into coherent stories and then answer first, second, and third order mentalizing questions about the characters' beliefs and intentions. The authors did not control for intellectual functioning and the control group had a significantly higher proportion of males than did the patient group. Performance on the mentalizing tasks did not differ between the patients and the controls and sex showed no effects on mentalizing ability; however, the authors did find that higher levels of maternal rearing behaviour that involved rejection and punishment negatively predicted were associated with lower mentalizing ability in the BPD patientsPerformance did not differ between the borderline group and control group on any domain of mentalization. only.

Preißler et al. (2010) assessed social-cognitive skills in 64 females with BPD and 38 non-clinical female subjects using two tasks; the “Movie for Social Cognition” (MASC; Dziobek et al., 2006) and the “Reading the Mind in the Eyes” Test (RMET; Baron-Cohen et al., 2001). The MASC involves subjects watching a film and then assessing the emotions, thoughts, and mental states of the characters, providing multidimensional social-cognitive stimuli that can detect subtle difficulties in mentalizing abilities. The RMET asks subjectsindividuals to infer mental states from the eye regions of photographed faces and it has been shown to reliably discriminate between control subjectspeople with and subjects without high-functioning autism. For the MASC, Preißler et al. (2010) found that borderline subjectspatients demonstrated reduced skill relative to healthy controls, while the RMET results suggested comparable skills in both groups. Consistent with some of the facial expression recognition research, Preißler et al. (2010) argued that the higher sensitivity of the MASC reveals a reduction in the ability of individuals with BPD to integrate complex social information, especially when time is constrained. In contrast, Fertuck et al. (2009) reported higher RMET scores in 30 subjectsindividuals with BPD (26 female) relative to 25 controls subjects (15 female). These divergent findings cannot easily be attributed to differences in intellectual functioning, as Preißler et al. (2010) matched the controls and borderline individuals on fluid IQ and Fertuck et al. (2009) matched the control and borderline groups on education level. However, as Preißler et al. (2010) pointed out, the increased proportion of males in the Fertuck et al. (2009) control group may have reduced control scores to a lower end of the range than iwhat is normally reported in control subjects, and therefore increased the probability of detecting group differences.

Scott et al. (2011) assessed mental state attribution as a function of borderline traits using the RMET in a non-clinical sample of undergraduate students. Based on a modified version of the Mclean Screening Instrument for BPD (MSI-BPD; Zanarini et al., 2003), 46 subjects (31 females) were assigned to the low-borderline condition and 38 subjects (25 females) were assigned to the high-borderline condition. The authors reported no difference in mental state decoding ability between the two groups for positive or neutral RMET stimuli, but for negative stimuli, the high-BPD group performed better than the low-BPD group. This difference was not attributable to group differences in response bias or affective state.

In addition to the empathy data discussed in the previous section, Harari et al. (2010) studied cognitive and affective components of theory of mind skills in the same study using the Faux-Pas Task (Baron-Cohen et al., 1999). In this task, cognitive theory of mind represents the understanding that within an interaction, a speaker and listener have different mental states. The affective component taps into a participant's appreciation of the emotional impact of a speaker's statement on a listener. SubjectsIndividuals listen to 20 stories and then answer questions that are designed to test their ability to detect a faux pas. The borderline subjectspatients were impaired in their detection and cognitive understanding of a faux pas relative to the control groupsubjects, but performed equally well in their affective understanding. Based on the combined results of both the Faux-Pas Task and the IRI, Harari et al. (2010) concluded that control groupssubjects demonstrate higher cognitive empathy relative to affective empathy while patients with BPD show the reverse pattern.

(6) Mentalization using interactive stimuli

Two studies have assessed borderline empathy in real social interactions between individuals with and without BPD. In a clinical setting, Ladisich and Feil (1988) had 20 borderline patients and 39 non-borderline psychiatric patients interact with one another and subsequently report on the feelings and qualities of themselves and other group members, using the Gieben Test (GT: Beckmann & Richter, 1972) and the Unpleasant Person Hierarchy Test (UPHT), a task designed specifically for this study. The composition of sex in the study groups was not reported. Empathic accuracy was assessed by comparing how closely perceivers could predict the self ratings of other group members. SubjectsPatients with BPD were more accurate in inferring the feelings of other patients than all other study subjects, including the participating psychiatrist.

Flury et al. (2008) assessed the association between borderline personality features and empathic accuracy in a sample of 76 undergraduate students (46 female) recruited from a larger sample of students whothat completed the Borderline Syndrome Index (BSI: Conte et al., 1980); only those individuals scoring in the upper and lower quartiles were included. Using a paradigm developed by Ickes (1993) and similar to Ladisich and Feil's study, Flury et al. (2008) estimated empathic accuracy by measuring each subject's ability to infer the thoughts and feelings of their partner in dyadic interactions between one high-borderline individual and one low-borderline individual. The authors reported significantly increased accuracy in ratings of the high-borderline group relative to the low-borderline group. To test for alternative explanations for this difference, the authors statistically controlled for stereotypical responding style and found that the borderline advantage disappeared though there was no significant difference in stereotypical responding between the two groups. After further analyses, the authors concluded that low-borderline participants tended to project their own personality characteristics onto those of their interaction partner, resulting in higher error rates due to the more unusual personality profile of the high-borderline subjects. Conversely, the high-borderline participants accurately assumed that their more atypical personality was not generalizable to their partner, and were therefore more accurate in their ratings. The authors concluded that the borderline advantage was attributable to differences in partner 'readability' and not empathic skill. These novel results provide an alternative interpretation of borderline empathy and also indicate the possibility of enhanced self-insight in individuals with borderline personality features.

In a third study using interactive stimuli, Franzen et al. (2011) compared the mentalizing processes of 30 BPD patients (22 female) with 30 non-patients in a simulated social interaction game developed for research in behavioural economics and decision-making. In a multi-round virtual trust game involving monetary unit exchanges between human and virtual (computer-screen) players, the researchers were able to experimentally manipulate the fairness and emotional cues exhibited by virtual players as well as the congruency between cues and actual behaviourbehavior. For some rounds of the game, players' emotional cues signalled fair behaviourbehavior (i. e., smiles) while in other rounds, the cues were inconsistent with level of fairness. The authors found that participants with BPD adjusted their playing strategy according to the objective fairness rather than the emotional cues of the virtual players. This finding could not be explained by group differences in emotion recognition or perceived fairness as both borderline patients and control subjects assessed these elements comparably. These authors concluded that individuals with BPD may thus process social information in a more controlled and deliberate manner, whereas control individuals may process emotional cues, especially salient facial expressions, more automatically.

Discussion

This review and synthesis has has assessed the existing evidence for the borderline empathy phenomenon across six domains ofa range of empathic skills. The degree to which empathic abilities are enhanced, comparable, or reduced among individuals with BPD compared to controls was highly variable across studies. However, a sufficient proportion of studies (13 of 27) and different tests (8 of 19) showed enhanced empathic skills in BPD to indicate that this phenomenon is worthy of further attention, and additional research effort designed to explain both the causes of borderline empathy and the among-study variation in results.

One possible cause of variation in results among studies is the nature of the social-empathic test deployed. Thus, in all three studies where empathic skills were examined in interactive social environments, individuals with BPD demonstrated increased abilities to accurately infer mental states and respond appropriately to the behaviour of others, relative to control subjects (Ladisich & Feil, 1988; Flury et al., 2008; Franzen et al., 2011). By contrast, in tasks requiring mental state attributions from passive stimuli, individuals with BPD demonstrated enhanced skills in two tests from three studies (Happé's Advanced ToM test, Arntz et al., 2009; RMET for negative emotions only, Scott et al., 2011; overall RMET score, Fertuck et al., 2009), conserved skills for three tests from four studies (MSAT, Ghiassi et al., 2010; affective understanding of faux pas, Harari et al., 2010; RMET, Preißler et al., 2010; RMET for positive and neutral emotions, Scott et al., 2011), and reduced skills for two tests from two studies (cognitive understanding of faux pas, Harari et al., 2010; MASC, Preißler et al., 2010). This apparent contrast in results between studies employingusing interactive and passive stimuli suggests that interactive, more ecologically-valid stimuli may be relatively more sensitive in demonstrating the skills of individuals with BPD, and therefore highlights the need for future research to examine borderline social cognition through interactive study environments and relativelymore realistic social interactions.

For other domainscategories of empathic skills, results were notably mixed. Assays of emotional intelligence suggested enhanced, reduced, orand conserved abilities in borderline subjects (Park et al., 1992; Hertel et al., 2009; Beblo et al., 2010). This variation in reported emotional intelligence may vary, in part, as a function of borderline symptom severity or overall cognitive ability. Taken togetherOverall, findings from facial expression recognition studies suggest that borderline individuals may have an increased sensitivity to negatively-valenced emotional stimuli, and thatthough factors such as reduced executive control may impair performance, especially in tasks requiring quick responses. Given that psychopathology is almost always associated with reduced performance in facial affect recognition (for one exception in schizophrenia research, see Davis & Gibson, 2000), the observation of enhanced borderline performance in four studies is especially noteworthy.

Studies comparing cognitive and affective empathic skills in BPD revealed a consistent and interesting pattern. Harari et al. (2010) reported reduced cognitive empathy but conserved affective empathy among individuals with BPD for measures assessing both empathizing and mentalizing abilities. Control subjects were characterized by higher cognitive empathy relative to affective empathy, whereas individuals with BPD demonstrated the reverse pattern; and given that the groups were matched for intellectual functioning, this pattern couldan not be attributed to group differences in intelligence. Similarly, Guttman & Laporte (2000) reported reduced cognitive empathy and enhanced affective empathy in individuals with BPD relative to control subjects. These studies are limited in that the ability of borderline subjects to accurately rate their own empathic skills is unknown, so results warrant a conservative interpretation. Given that both studies reported reduced cognitive empathy and either normal or enhanced affective empathy, it is possible that borderline empathy is characterized by a dissociation or asymmetry between these different facets of empathic skill (Harari et al., 2010).

Empathic deficits are often implicated as etiologically central to psychopathology, due to the impaired social functioning characteristic of individuals with psychiatric diagnoses (Cameron, 2009). Indeed, a substantial body of literature indicates reduced social competency for individuals with the Axis I disorders that share psychotic-affective symptomsatology with BPD, including major depression, bipolar disorder, and schizophrenia (e. g., Barnow et al., 2010; Glaser et al., 2010; Hooley, 2010; Judd et al., 2000; Lieb et al., 2004; MacQueen et al., 2001; Perugi et al., 2011Hooley, 2010). Although it is reasonable to assume that social interactions are facilitated through the effective use of both basic empathic skills like emotion recognition and more complex skills like mental state attribution, impairments to overall social functioning may, in principle, result from either reductions or increases in specific abilities from normative levels (Crespi & Badcock 2008; Montag et al. 2010; Sharp et al. 2011). For example, Langdon et al. (2006) studied attentional orienting as a function of gaze shifting in people with and without schizophrenia and found that individuals with schizophrenia were hyper-responsive to gaze, reflexively shifting their attention in the direction indicated by another's gaze at a lower threshold thean did subjects without non- schizophrenicsa. This automatic and increased sensitivity to gaze may be linked to the tendency of schizophrenicsindividuals with schizophrenia to over-perceive intentionality and experience paranoia, both of which may contribute to the social difficulties observed in these individualsschizophrenia. Similarly, excessive levels of empathy may potentiate or exacerbate depression, and anxiety, and borderline features, especially among females (Damman 2003; O'Conner et al. 2007; Zahn-Wexler et al. 2006; Zahn-Wexler et al. 2008). The observation of general social deficits in individuals with psychotic-affective conditions is thus not necessarily sufficient to indicate reductions in the empathic skills that underlie social functioning, because such deficits could result from qualitatively- distinct alterations to empathic skills. Whether alterations involve reductions or enhancements into specific empathic domains may thus be useful in forming hypotheses for the causes of these conditions. But how might enhanced empathic abilities be related to severe deficits in interpersonal functioning in BPD?

Resolving the borderline empathy paradox

Psychoanalytic accounts attribute borderline empathy to environmental causes, such that in response to inconsistent or neglectful parenting and in an effort to maintain a constant view of the caregiver object, the borderline individual develops enhanced sensitivity to the subtle, subconscious cues indicating the mental states of the parent (Krohn, 1974; Carter & Rinsley, 1977). The tendency to perceive and respond to subconscious drives, combined with a learned distrust of conscious behaviourbehavior, thus disrupts the ability of the borderline individual to develop enduring and stable experiences of others in interpersonal contexts, which leads to lasting social dysfunction. This model is supported by evidence suggesting a relationship between maternal neglect and enhanced nonverbal decoding abilities, whereby increased reports of maternal neglect positively predicted scores on the PONS in borderline subjects (Frank & Hoffman, 1986). Linehan (1993) similarly proposed that BPD is characterized by a heightened sensitivity to, and keen awareness of, emotional cues, especially negative cues signalling rejection or abandonment, in the social environment. The origins of this enhanced sensitivity are suggested to be biological in nature, although emotionally invalidating environments - such as the childhood abuse and neglect that is often reported in BPD cases - are expected to exacerbate innate empathic sensitivity. Under this hypothesis, the social difficulties characteristic of BPD result from low thresholds of emotional reactivity and insecure appraisals of emotional events based on accurate perceptions of social cues (Wagner & Linehan, 1999).

Park et al. (1992) also attributed borderline empathy and its role in BPD development to interacting biological and environmental factors, though these researchers emphasized the positive aspects of enhanced empathic skills and referred to them as cognitive ‘gifts’ involving the desire and ability to understand the thoughts and feelings of others, that, in the absence of abuse, would contribute to an individual's well-being and not result in BPD. Fertuck et al. (2009) suggested that enhanced mentalizing in BPD engenders reduced interpersonal functioning through a combination of negative expectations upon entering social interactions and reduced executive cognitive control, resulting in the inability to modify incorrect appraisals of social situations. Similarly, Arntz et al. (2009) suggested that impulsivity, emotional reactivity, and working memory deficits observed in BPD may inhibit the borderline individual's ability to apply intact mentalizing skills in emotionally charged situations, therefore contributing to social dysfunction.

Drawing from the reviewed studies, we suggest that the borderline empathy paradox may be attributable in part to a combination of enhanced attention to, and perception of, social stimuli with dysfunctional processing of social stimuli. Under this model, many individuals with BPD may exhibit increased attention to social stimuli, and thus develop enhanced abilities to perceive social information. Such enhanced attention and perception may become pathological if it interacts with deficits in other domains such as attentional control, emotion regulation, and regulation of the attachment system, such that the inferences drawn from social information become amplified and distorted towards negative, self-referential emotional states. This model is consistent with previous evidence of hyper-sensitivity to the social environment in BPD (Lynch et al. 2006; Gunderson and Lyons-Ruth 2008; Goodman and Siever 2011), which involves constant vigilance to anticipated rejection (Fertuck et al. 2009), and difficulties in regulating emotion due to a low thresholds for stress-related activation of the attachment system and deactivation of controlled mentalization (Fonagy et al. 2011). . Such stress and emotion mediated deactivation of controlled mentalization should be unlikely to reduce performance on the laboratory-based empathic-skill tests analyzed here, which could help to explain preservation of empathic abilities in individuals with BPD but cannot explain enhancements. High sensitivity and attention to social cues may also engender hyper-mentalizing (overly-complex inferences based on social cues), which can interact in a vicious cycle with dysregulated emotionality through anxious, uncontrolled rumination (Sharp et al. 2011). Finally, tTo the extent that conscious or unconscious mental states of social interactants indeed reflect negatively upon individuals with BPD but remain verbally unexpressed, highly sensitive and accurate empathic inferences that reveal such states may also exacerbate BPD symptoms by instigating emotional dysregulation and dysfunctional interactions. This model based on enhanced attention to, and perception of, social stimuli in BPD is conceptually analogous to models of autism spectrum disorders, where increases have been observed in attention to, and perception of, non-social compared to social stimuli (Mottron & Burack, 2001; Mottron et al. 2006; Baron-Cohen et al., 2009; Klin et al. 2009; Pierce et al. 2011).Finally, hHigh sensitivity and attention to social cues may also involveengender hyper-mentalizing (overly-complex inferences based on social cues), which canmay interact in a vicious cycle with dysregulated emotionality through anxious, uncontrolled rumination (Sharp et al. 2011).

Drawing from the reviewed studies, we suggest that the borderline empathy paradox may be attributable in part to a disconnect between combination of enhanced attention and perception withand dysfunctional processing of social stimuli. Under this model, many individuals with BPD may exhibit increased attention to social stimuli, and thus develop enhanced abilities to perceive social information. Such enhanced perception may become pathological ifwhen it interacts with deficits in other domains such as attentional control and emotion regulation. Findings from Gardner et al. (2010) and Lynch et al. (2006) are consistent with this model; in the former study, BPD traits predicted enhanced recognition of anger, but only when executive control was also high; in the latter study, individuals with BPD correctly identified the emotion of morphing facial expressions earlier than did healthy controls, suggesting an enhanced perception of emotional cues. Borderline empathy may thus involve dysregulation to the integrated social cognitive-affective system, resulting in a characteristic asymmetry or splintering of empathic skills. The dissociation between cognitive and affective empathy observed by Harari et al (2010) and Guttman and Laporte (2000) may also be consistent with this model, in that affective empathy may be more closely linked to the immediate perception of social cues and accompanying physiological responses, whereas cognitive empathy involves higher order cognitive functions (Shamay-Tsoory, 2011). Gaining an understanding of the specific pattern of cognitive-affective enhancements and reductions in individuals with BPD should further clarify the relationship between borderline and normal social cognition, as well as elucidate the role of enhanced empathy in BPD etiology. Findings from Gardner et al. (2010) and Lynch et al. (2006) are also consistent with this general model for helping to explain the borderline paradox. Thus, in the former study, BPD traits predicted enhanced recognition of anger, but only when executive control was also high; in the latter study, individuals with BPD correctly identified the emotion of morphing facial expressions earlier than did healthy controls, suggesting enhanced perception of emotional cues. Borderline empathy may thus involve dysregulation to the integrated social cognitive-affective system, resulting in a characteristic asymmetry or splintering of empathic skills (Fonagy et al. 2011). The dissociation between cognitive and affective empathy observed by Harari et al (2010) and Guttman and Laporte (2000) may also be concordant with the model, in that affective empathy may be more closely linked to the automatic and immediate perception of social-emotional cues and accompanying physiological responses, whereas cognitive empathy involves higher order cognitive functions (Shamay-Tsoory, 2011).  Borderline empathy may thus involve dysregulation to the integrated social cognitive-affective system, resulting in a characteristic asymmetry or splintering of empathic skills (Fonagy et al. 2011). Gaining an understanding of the specific pattern of cognitive-affective enhancements and reductions in individuals with BPD, and their interactions with social attention and perception, attentional control, and emotion regulation, should clarify the relationship between borderline and normal social cognition, as well as elucidate the role of enhanced empathy in BPD etiology and symptoms.

Also salient to a model of BPD involving, in part, a maladaptive enhancement of attention to social stimuli is evidence for enhanced performance of individuals with BPD on tasks that typically demonstrate female superiority in non-clinical populations, and corresponding reduced performance in tasks with a male advantage (Table 1). It is important to note that most tasks in Table 1 are linked to a female advantage, given that overall, females appearseem to outperform males in the general domain of social cognition (i. e., Geary 2010). Females thus outperform males in facial emotion recognition for a variety of tasks and stimuli (reviewed in Geary, 2010); four studies reported superior performance of borderline subjects in this domain (Wagner & Linehan, 1999, Lynch et al., 2006, Gardner et al., 2010, Merkl et al., 2010). For self-reported affective empathy assessed by the IRI (Davis, 1980, 1993), Guttman & Laporte (2000) reported enhanced scores for borderlines relative to controls while Harari et al. (2010) reported no difference. Studies using the IRI in non-clinical samples of both adolescents and adults have found a female advantage in the subscales composing the affective empathy score (Mestre et al., 2009; Berthoz et al., 2008). Females also outperform males on tasks requiring the attribution of mental states from photographs of the eyes (RMET; Baron-Cohen et al., 1997; Baron-Cohen et al., 2001). For this task, Preißler et al. (2010) found no group differences whereas Fertuck et al. (2009) reported enhanced performance of the borderline subjects relative to non-BPD controls. Scott et al. (2011) reported higher RMET scores for negative emotional stimuli in healthy adults with borderline personality features compared to adults without borderline personality features.

For higher-order theory of mind tasks, female superiority is often assumed, although performance of the sexes is dependent on the specific task employed. For example, Russell et al. (2007) reported a male advantage for Happé's cartoon task but Bosacki (2000) reported female superiority on a similar task in healthy pre-adolescents. With respect to BPD, Arntz et al. (2009) found enhanced performance of the borderline group relative to non-clinical control subjects on Happé's (1994) Advanced ToM task. IInterpretation of these results is severely limited by the relatively lack, or absence, of male subjects in most studies of BPD;. fFuture research examiningneeds towould benefit from comparinge male and female performance in both borderline and non-clinical populations, in order to provide a advancefurther understanding of both male and female borderline performance on tasks where gendersex differences are relatively well established in non-clinical populations will be valuable in providing a further understanding of borderline phenotypes in the context of sex differences in social cognition.

Conclusions

Through critically examining the evidence bearing on enhanced empathic skills in borderline populations, this review has provided the groundwork for future test of hypotheses concerning both the causes of borderline empathy and the role of empathic enhancements in BPD etiology, symptoms, and therapy. Given the evidence regarding the borderline empathy phenomenon, we have suggested that the causal bases underlying BPD may involve, in part, a pathological and selective enhancement of normally adaptive empathic abilities, especially with regard to increased attention to social stimuli. More generally, increased understanding of the role that social brain adaptations play in mediating human psychiatric disease risk may help to explain maladaptations of human social interactions, especially for conditions such as borderline personality disorder that centrally involve interpersonal relationships.

Enhancements and impairments in BPD and autism spectrum disorders

A model based on disconnection between enhanced attention and perception, and dysfunctional processing, with respect to social stimuli in BPD is conceptually analogous to models of autism spectrum disorders (ASD), where enhancements have been observed in attention to, and perception of, non-social rather than social stimuli (Mottron & Burack, 2001; Mottron et al. 2006; Baron-Cohen et al., 2009; Klin et al. 2009; Pierce et al. 2011). Thus, although autism is characterized by social deficits, impaired reciprocal communication, and restricted interests and repetitive behaviourbehavior, individuals with this diagnosis also tend to differentially demonstrate strengths in various areas of sensory detection and mechanistic cognition, such as excellent attention to detail and enhanced pattern recognition abilities (Baron-Cohen et al., 2005; Baron-Cohen, 2009; Baron-Cohen et al., 2009). A notable suite of studies has also indicated enhanced auditory and visual discrimination abilities in individuals with autism, particularly at early stages of information processing (Bertone et al., 2003; Bonnel et al., 2003; Baron-Cohen et al., 2009). At their highest level of development, such abilities present as savantism, the presence of extraordinary islets of ability, in 0.5-10% of people with autism. Such abilities are approximately six times appear to be more common in males than females, and tend to be mechanistic in nature, including skills like perfect pitch, hyperlexia, mathematical giftedness, calendar counting, realistic drawing, and memorization (Treffert, 2009).

Enhanced perceptual, systemizing, and mechanistic skills, which appear to develop in part from increased attention to non-social details in the environment as well as tendencies towards repetitive and restrictive interests and activities (Drake et al. 2010; Happé & Vital 2009), may contribute to disrupting the development of more complex cognitive and social-behaviourbehavioral abilities, in addition to forming the basis for autistic talent (Baron-Cohen et al., 2009; Mottron et al., 2006; Vital et al. 2009). The primary parallel between enhanced abilities in autism spectrum conditions, and in BPD, is that in both conditions notably-increased, highly-selective levels of attention and interest towards particular forms of stimuli (non-social and social, respectively) may mediate both the development of specialized skills and the development of deficits in other features and functions of cognition and affect. This conceptual model for helping to explain the 'borderline empathy' paradox is concordant with more-general, comprehensive accounts of BPD etiology, which focus on lower thresholds for social attachment, lower thresholds for deactivation of controlled mentalization, and hyper-vigilance regarding the emotional states of others (Fonagy & Luyten 2009).

To explain the symptoms and correlates of autism in addition to the male bias in its prevalence, Baron-Cohen et al. (2005) and Baron-Cohen (2009) have forwarded the empathizing-systemizing (E-S) theory, a framework for understanding sex differences in cognition. In contrast to empathizing as a tool for understanding the social world, systemizing describes the drive to predict and control the behaviourbehavior of rule-based physical systems; females tend to employ greater empathizing relative to systemizing, while on average, males demonstrate the opposite pattern (Baron-Cohen, 2002, 2009; Baron-Cohen et al., 2005). Individuals with autism show an exaggerated form of the male cognitive profile, with reduced empathizing and enhanced systemizing. This male-typical profile is consistent with the strong male sex-ratio bias observed in autism, which also increases in milder expressions of the condition (Baron-Cohen, 2002, 2009). Overall, the male bias in autism and savantism skills, as well as the exaggerated male cognitive style characteristic of individuals with ASD, support Baron-Cohen's (2002, 2009) conceptualization of autism as involving the 'extreme male brain'.

Evidence for enhanced empathic skills in BPD, higher female performance on the same or comparable empathy-related tasks in non-clinical populations, and observations of a strong (~75%) female sex-ratio bias in clinical populations of individuals with BPD (meta-analysis in Widiger & Trull, 1993; but see also Grant et al. 2008; Paris 2010; and Skodol & Bender, 2003), suggest that BPD contrasts directly with autism, which is characterized, as described above, by reduced empathy, a male sex-ratio bias, and other characteristics of an 'extreme male brain' (Baron-Cohen 2002, 2009).Evidence for enhanced empathic skills in BPD, and higher female performance on the same or comparable empathy-related tasks in non-clinical populations, suggest that BPD contrasts directly with autism, which is characterized, as described above, by reduced empathy and other characteristics of an 'extreme male brain' (Baron-Cohen 2002, 2009). Moreover, BPD has also been observed to exhibit a female sex-ratio biases in diagnoses among many clinical populations (Widiger & Trull, 1993; Corbitt & Widiger 1995) as well as in BPD symptomatology among some community samples (Distel et al. 2008; Aggen et al. 2009; De Moor et al. 2009; Furnham and Trickey 2011), although this latter bias has not been observed in some studies (Jane et al. 2007; Grant et al. 2008). The concept of an 'extreme female brain' in relation to psychiatric conditions has yet to be considered in detail, although Zahn-Wexler et al. (2008) develop this idea in describing how enhancements or precocial development of empathic social skills in females may, especially in dysfunctional environments, predispose to depression and anxiety (see also O'Connor et al. 2007). Similarly, Dammam (2003) hypothesized that in direct contrast to the reduced empathy observed in autism, female-preponderant mentalization disorders such as BPD are mediated by pathological hypersensitivity to empathy. In contrast to these perspectives, Baron-Cohen (2002) dismissed the role an 'extreme female brain' in psychopathology,the role of an 'extreme female brain' in psychopathology, suggesting that unlike autistic individuals, people with enhanced empathizing skills should fit well into society, though they would be predicted to have difficulties in tasks that involve math, science and engineering.

Positive associations have been reported between empathy and aspects or measures of psychotic-affective phenotypes in several studies. Thus, Brosnan et al. (2010) studied the relationship between empathizing, systemizing, and psychotic-affective phenotypes using questionnaires in a non-clinical sample of female adults, and found that a hyper-empathizing profile predicted increased reports for both mania and paranoia. Similarly, Henry et al. (2008) reported a positive correlation between self-reported cognitive empathy and positive schizotypy, and Asai et al. (2011) found that empathic concern was positively related to both positive schizotypy and susceptibility to a 'rubber hand' illusion. Additional studies that relate measures of empathy to aspects of psychotic-affective conditions, in relation to sex differences in clinical and non-clinical populations, are required for further evaluation of these findings.

Conclusions

Through critically examining the evidence bearing on enhanced empathic skills in borderline populations, this review has provided the groundwork for future test of hypotheses concerning both the causes of borderline empathy and the role of empathic enhancements in BPD etiology, symptoms, and therapy. Given the evidence regarding the borderline empathy phenomenon, we have suggested that the causal bases underlying BPD may involve, in part, a pathological and selective enhancement of normally adaptive empathic abilities, especially with regard to increased attention to social stimuli. More generally, increased understanding of the role that social brain adaptations play in mediating human psychiatric disease risk may help to explain maladaptations of human social interactions, especially for conditions such as borderline personality disorder that centrally involve inter-personal relationships.

Acknowledgements

We are grateful to NSERC for financial support, and and to FAB* Lab to and Alexander Chapman for helpful

Acknowledgements

We are grateful to Felix Breden, Alex Chapman, three anonymous reviewers, and members of the the Simon Fraser University Fab-Lab and the University of California-Santa Barbara Center for Evolutionary Psychology for helpful comments and discussion, and we thank NSERC for finanical support.

comments and discussion.

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Table 1. Studies reporting enhanced, reduced, or comparable empathic skills in BPD

|Empathic domain |N |Study |Task |Sex difference on |Subjects |BPD performance relative to controls |

| | | | |task in | | |

| | | | |non-clinical | | |

| | | | |populations | | |

| | | | | |Enhanced |Reduced |Comparable | |Nonverbal sensitivity |1 |Frank & Hoffman 1986 |Profile of Nonverbal Sensitivity |Female advantage (1) |10 BPD femalessubjectspatients & 14 non-BPD clinical controls (100% female) |p < 0.02 | | | |

Emotion recog-nition |

11 |Levine et al. 1997 |Pictures of Facial Affect (PFA) |Female advantage (1) |30 BPD patients (2067% female females) & 30 non-clinical controls (1550% females) | |p < 0.001 | | | | |Wagner & Linehan 1999 |Japanese and Caucasian Facial Express. of Emotion |Female advantage (1) |21 BPD femalessubjects with history of sexual abuse & 41 non-BPD femalessubjects (with and without history of abuse) (100% female) |p < 0.05 (fear) |p < 0.05 (neutral) |p = n.s. (happy) | | | |Bland et al. 2004 |PFA

|Female advantage (1) |35 BPD patientssubjects & 35 non-clinical controls (100% female) | |p = 0.007 | | | | |Lynch et al. 2006 |PFA |Female advantage (1) |20 BPD patients (1785% females) & 20 non-clinical controls (1785% female) |p < 0.05 | | | | | |Minzenberg et al. 2006 |PFA

BLERT* |Female advantage (1) |43 BPD patients (3888% females) & 26 non-clinical controls (89% female) | |p = 0.02 | | | | |Domes et al. 2008 |PFA |Female advantage (1) |25 BPD patientssubjects & 25 non-clinical femalescontrols (100% female) | | |p = 0.925 | | | |Dyck et al. 2009 |FAN test**

ER Test*** |Female advantage (1) |19 BPD patients (1789% females) & 19 non-clinical controls (17 females)89% female) | | |p = 0.5

p = 0.58 | | | |Guitart-Masip et al. 2009 |PFA |Female advantage (1) |10 BPD patients (50% females) & 10 non-clinical controls (50% females) | |p = 0.01 (disgust) |p = n.s. (happy & angry) | | | |Merkl et al. 2010 |PFA |Female advantage (1) |11 BPD patientssubjects and 9 non-clinical femalescontrols (100% female) |p = 0.04 (fear) | |p = n.s. (other emotions) | | | |Gardner et al. 2010 |PDQ-4-BPD****

ATQ*****

PFA

|Female advantage (1) |150 non-clinical adults (70% females) |high ATQ & high BPD positive- ly predict anger recogni-tion

p < 0.001 |low ATQ & high BPD

negatively predict

anger recogni-tion

p < 0.001 | | | | |Unoka et al. 2011 |Ekman 60 Faces Test |Female advantage (1) |33 BPD patients (2988% females) & 32 non-clinical controls (30 94% females) | |p < 0.0001 | | |Self-reported empathy

|2 |Guttman & Laporte 2000 |Interpers-onal Reactivity Index |Female advantage (2, 3) |27 BPD patientssubjects & 28 clinical control femaless & 27 non-clinical control femalesls

(100% female) |p < 0.01 (affect-ive empathy) |p < 0.01 (cognitive empathy) | | | | |Harari et al. 2010 |Interper-sonal Reactivity Index |Female advantage (2, 3) |20 BPD patients (1890% females) and& 22 non-clinical controls (1986% females) | |p = 0.038 (cognitive empathy) |P = 0.205 (affective empathy) | |Emotional intelli-gence |4 |Park et al. 1992 |Derived scale from Gardner's personal intelli-gence concept |Unknown; task designed specifically for this study |23 BPD patients (1878% female) & 38 outpatients with other PD diagnoses (61% female) |p < 0.01 | | | | | |Hertel et al. 2009 |Mayer-Salovey-Caruso Emotional Intelli-

gence Test (MSCEIT) |Female advantage (4) |19 BPD females patients (100% female) & 66 patients with other mental disorders (3045% females) & 94 non-clinical controls (637% females) | |p < 0.01 | | | | |Gardner & Qualter 2009 |Multiple BPD measures

MSCEIT

Schutte Emotional Intelli- gence Scale (SEIS) |Female advantage (4, 5) |523 non-clinical adults (77.778% female) | |Overall BPD score negatively predicted overall trait and ability EI

p < 0.001 |Ability to perceive emotions not related to BPD score

p = n.s. | | | |Beblo et al. 2010 |MSCEIT

Test of Emotional Intelli-gence

(TEMINT) |Female advantage (4, 6) |19 BPD patients (1684% female) & 20 non-clinical controls (1785% female) | | |p = 0.264

p = 0.10 | |

Mentalizing skills using passive stimuli |

6 |Arntz et al. 2009 |Advanced Theory of Mind Test |Mixed (7, 8) |16 BPD patientssubjects & 16 cluster-C PD femalessubjects and 28 non-clinical controls females(100% female) |p < 0.07 | | | | | |Fertuck et al. 2009 |Reading the Mind in the Eyes Test (RMET) |Female advantage (9) |30 BPD patients (2687% female) & 25 non-clinical controls (1560% females) |p < 0.001 | | | | | |Ghiassi et al. 2010 |Mental State Attribution Task- Sequencing and Question-naire |Unknown for this particular task |50 BPD patients (4692% female) & 20 non-clinical controls (1785% females) | | |p = n.s. | | | |Harari et al. 2010 |Faux-Pas Task |Female advantage (10) |20 BPD patients (1890% female) and non-clinical controls | |Cogni-tive under-standing

p = 0.027 |Affect-ive

under-standing

p = 0.423 | | | |Preibler et al. 2010 |Movie for Assessment of Social Cognition (MASC)

RMET |Females = males (11)

Female advantage (9) |64 females with BPD patientssubjects & 38 female non-clinical controlssubjects (100% female) | |p = 0.001 |

p = 0.58 | | | |Scott et al. 2011 |MSI-BPD******

RMET |Female advantage (9) |46 undergraduate students (3176% females) |High BPD group more accur-ate for nega-tive emo-tions

p < 0.05 | |No group differ-ences for positive and neutral emotions

p = n.s. | |Mentalizing skills using interactive stimuli |3 |Ladisich & Feil 1988 |Gieben Test (GT)

Unpleasant Person Hierarchy Test (UPHT) |Unknown

Task designed specific-ally for this study |20 BPD patients (sex composition not reported)& 39 non-BPD psychiatric patients

(sex composition not reported) |p < 0.05 | | | | | |Flury et al. 2008 |Infer states of partner in dyadic interactions |Unknown |76 undergraduate students (4661% female) |High BPD group more accure-ately

p < 0.01 | | | | | |Franzen et al. 2011 |Simulated interaction game with monetary exchange |Unknown |30 BPD patients (2273% female) & 30 non-clinical controls (2273% female) |p < 0.003 | | | |

Notes: *Bell-Lysaker Emotion Recognition Test; **Fear-Anger-Neutral Test; ***Emotion Recognition Test; ****Personality diagnostic questionnaire-fourth edition-BPD scale; *****Adult temperament questionnaire-short form; ****** Mclean Screening Instrument for BPD

References 1) Geary 2010; 2) Mestre et al. 2009; 3) Berthoz et al. 2008; 4) Day & Carroll 2004; 5) Schutte et al. 1998; 6) Amelang & Steinmayr 2006;

7) Bosacki 2000; 8) Russell et al. 2007; 9) Baron-Cohen et al. 2001; 10) Baron-Cohen et al. 1999; 11) Smeets et al. 2009

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