The present study comprises a systematic empirical assessment of social cognition in patients with BPD using a more ecologically valid instrument. Whereas the RME task failed to detect significant impairments in social cognition in patients with BPD, the more ecologically valid MASC clearly identified significant impairments. Patients with BPD were impaired in the recognition of the feelings, thoughts, and intentions of the starring movie characters. Thus, our results support evidence from former studies (Fonagy et al., 1996
; Harari et al., 2010
) and are in contrast to findings of unimpaired or enhanced social cognition abilities (e.g., Arntz et al., 2009
; Fertuck et al., 2009
The result of preserved performance on the RME task in BPD is in line with previous findings reporting no deficits in facial emotion recognition for simple tasks with no time limits or additional confounding variables (Domes et al., 2009
). However, these findings stand in contrast to the finding of Fertuck et al. (2009
), who reported enhanced RME performance in BPD. In the Fertuck et al. (2009
) study, significantly more men were included in the control group. Men are reported to be less accurate, as well as less sensitive in labeling facial expressions (Montagne et al., 2005
). Also, controls from that study performed at the lower end of the range when compared to controls from other studies using the RME task (Fertuck et al., 2009
). Further, a higher percentage of Non-Caucasian participants were in the control group, whereas in the BPD group most participants were Caucasian and the RME tasks displays eye-regions of Caucasians (Fertuck et al., 2009
). Our results also contradict the findings of Arntz et al. (2009
) who found that borderline patients had no significant impairment in a “theory of mind” task based on completion of mental stories (Happé, 1994
), compared to Cluster C patients and controls. In contrast to the advanced “theory of mind” task (Happé, 1994
) applied by Arntz et al. (2009
), we used the more complex and ecologically valid film material presented by the MASC. In this task, patients with BPD displayed significant impairments. These results are in line with former studies of emotion recognition, indicating that patients with BPD show deficits in the fast discrimination of negative and neutral facial expressions (Dyck et al., 2009
). In addition, complex tasks for assessing emotion recognition with integrated facial and prosodic stimuli revealed impairments for patients with BPD (Minzenberg et al., 2006
). The results of impaired social cognition measured by the MASC, especially in the recognition of intentions, are in line with a previous study showing that mental state reasoning capacities are compromised in BPD (Fonagy and Bateman, 2006
In summary, our results support the notion that higher-order integration of social information within a limited time frame is impaired in patients with BPD. Further, we extended these findings of impaired emotion recognition to thoughts and intentions, which seem to be even more impaired in BPD.
The present findings of impaired social cognition can explain several clinical symptoms of BPD. Deficits in correctly identifying the emotions, thoughts, and intentions occurring in social situations could result in fear of abandonment, alternating between extremes of idealization and devaluation of other persons, and subsequent suicidal gestures or threats. Further studies are needed to assess the cognitive and behavioral impacts of impaired social cognition in BPD.
In the present study our preliminary analyses identified three factors contributing to impaired social cognition in BPD: intrusive symptoms, comorbid PTSD, and sexual assault by a known assailant. Intrusiveness as measured by the BSL in the patient group negatively predicted outcomes on the MASC, especially for recognition of thoughts. Also, comorbid PTSD was associated with impairment in social cognition in BPD, especially for recognition of thoughts and intentions. Intrusions are core symptoms of PTSD; thus, both results argue for a negative impact of PTSD on social cognition. PTSD has been described as associated with low IQ and executive function deficits (e.g., Gilbertson et al., 2006
). Both could contribute to findings of impaired social cognition in BPD patients with comorbid PTSD. Although influence of fluid IQ on social cognition was not significant in our data, further studies are needed to address this topic. Also, suppression of intrusive thoughts, which has been shown to have a negative impact on working memory (Brewin and Smart, 2005
), could thereby have a negative impact on attention and thus contribute to impaired social cognition task performance in patients with comorbid PTSD. Thus, our results are in line with and extend previous findings of evidence for disturbed processing of negative or threatening visual information, as well as deviant neural responses to negative facial emotion expression in patients with PTSD (Shin et al., 2005
Furthermore, our results provide preliminary evidence for the finding that sexual assault by a known assailant is associated with impaired social cognition. These findings are of special interest as adult BPD is associated with high rates of childhood maltreatment (Zanarini, 2000a
). Patients with BPD report more types of abuse in childhood, beginning earlier in life, and repeated over longer periods of time than for comparison groups (Zanarini et al., 1997
). As 54.1% of patients with BPD without comorbid PTSD reported sexual assault by a known assailant, this trauma with comorbid PTSD seems to be a partially independent risk factor. Nevertheless, trauma type assessment was based on the self-reported PDS scale. Thus, further studies are needed to assess more precisely the impact of trauma and trauma type on social cognition in BPD. In previous studies, severity of borderline pathology correlated with severity of childhood abuse, especially sexual abuse (Silk et al., 1995
). In the present study, patients with BPD with and without PTSD, and with and without a history of sexual abuse did not significantly differ in severity of BPD symptoms. Thus, in our sample, severity of BPD did not significantly account for the finding of more impaired social cognition in comorbid PTSD or for patients with a history of sexual abuse.
Referring to the concept of the gene-environment interaction as a contributing factor to the development of psychiatric disorders, one could speculate about the genetic origins of the deficits in social cognition, as BPD has high heritability (Torgersen et al., 2008
). However, our results argue for at least an additional environmental component, given that intrusions, PTSD, and sexual abuse point to the presence of environmental strains.
Interestingly, emotion dysregulation as a core feature of BPD (Sanislow et al., 2002
), as assessed using the BSL, did not significantly account for impaired social cognition in our analysis within the BPD group, possibly indicating impaired social cognition as part of an independent factor of disturbed relatedness within BPD.
The findings of intrusive symptoms, comorbid PTSD, and a history of sexual abuse as predictors for impaired social cognition can be interpreted within the actual knowledge of the neural basis of social cognition.
In the present study, emotion recognition in BPD, as measured by the MASC, was less prominently impaired than recognition of intentions in the total BPD sample compared to controls. Simulation theory proposes that we can understand the mental states of others on the basis of our own mental state (Gallese and Goldman, 1998
). Through recognizing the facial expression of another person we infer that person's emotional state and attribute the emotion to the encounter. This process seems to be more basal, referring less to higher cognitive functions, and is less prone to learned knowledge about social interactions (Frith and Frith, 2006
). The finding of less impaired emotion recognition as compared to the recognition of intentions for the present MASC task for BPD patients indicates less impairment in this more basal social cognitive process.
Experiential learning is crucial for our ability to recognize the thoughts and intentions of others in social encounters. The temporal pole, the medial prefrontal cortex, and the adjacent paracingulate cortex seem to be involved in that process (Damasio et al., 2004
). Thus, more prominent impairment in the recognition of intentions and, for patients with intrusions and comorbid PTSD, more impairment in the recognition of thoughts and intentions, may indicate that environmental factors like trauma influence these learning-dependent capacities, which might be related to deficits in the frontal lobe. Imaging data support the notion of frontal brain dysfunction in patients with BPD (Schmahl and Bremner, 2006
), with possible additional impairment of frontal neural networks in BPD patients with comorbid PTSD (Driessen et al., 2004
). Also, our finding of history of sexual assault by a known assailant as a predictor for impaired social cognition could represent an indicator of an invalidating environment where adequate social learning was hindered for the child while growing up.
Our study has several limitations. The results do not imply that a deficit in social cognition is specific to BPD. By contrast, such deficits have been described in a number of psychiatric disorders (e.g., euthymic bipolar patients, Montag et al., 2010
; Asperger individuals, Dziobek et al., 2006
). Thus, concluding from our results, follow-up studies are needed to assess social cognition abilities in PTSD patients after mono-trauma or chronic traumatization and in individuals without PTSD after trauma, especially after sexual traumatization, to further explore our findings. Additionally, the sample size of n
102 was capable of detecting only large effects with a power of 0.80. Finally, results were restricted to women with BPD.
Our data have several clinical implications. Deficits in social cognition in patients with BPD, especially with comorbid PTSD, should be considered in psychotherapy. Also, a history of sexual abuse as a predictor for impaired social cognition should be taken into account. Presumed emotions, thoughts, and intentions of interaction partners are often triggers of dysfunctional behavior in BPD. Thus, a reanalysis of these social triggers should be included in psychotherapy. Also, the emotions and cognitions of the therapist him- or herself should not be assumed to be accurately understood by the patient, but rather should be explicitly expressed. Moreover, psychotherapeutic strategies and trainings for enhancing social cognitive abilities should be integrated into the treatment of this patient group, with special respect to PTSD and traumatic experiences. Although different psychotherapeutic programs such as Dialectic Behavior Therapy, Transference Focused Psychotherapy, Schema Focused Therapy, Supportive Psychotherapy, and Mentalization-Based Therapy, which all address social cognition in their own ways, have proven effective in the treatment of BPD (de Groot et al., 2008
), information on their capacities to improve social cognition is still lacking.
In summary, the present study provides additional valuable empirical evidence for impaired social cognition in patients with BPD. In particular, PTSD symptoms and sexual trauma caused by a family member or acquaintance predict poor outcomes on social cognition tasks.