
==== Front
Borderline Personal Disord Emot Dysregul
Borderline Personal Disord Emot Dysregul
Borderline Personality Disorder and Emotion Dysregulation
2051-6673
BioMed Central London

37259167
224
10.1186/s40479-023-00224-1
Research
Psychopathology and Theory of Mind in patients with personality disorders
https://orcid.org/0000-0003-0690-0731
Burghardt Juliane 1
https://orcid.org/0000-0002-4025-4262
Gradl Silvia silvia.gradl@kl.ac.at

123
https://orcid.org/0000-0001-9761-7362
Knopp Magdalena 13
https://orcid.org/0000-0003-0315-0912
Sprung Manuel 12
1 https://ror.org/04t79ze18 grid.459693.4 0000 0004 5929 0057 Division of Clinical Psychology, Department of Psychology and Psychodynamics, Karl Landsteiner University of Health Sciences, Dr.-Karl-Dorrek-Straße 30, Krems an Der Donau, 3500 Austria
2 University Hospital for Psychosomatic Medicine Eggenburg, Grafenberger Straße 2, Eggenburg, 3730 Austria
3 https://ror.org/05591te55 grid.5252.0 0000 0004 1936 973X Faculty of Psychology and Educational Sciences, Department of Psychology, Ludwig-Maximilians-Universität München, Leopoldstraße 13, Munich, 80802 Germany
1 6 2023
1 6 2023
2023
10 1819 1 2023
9 5 2023
© The Author(s) 2024, corrected publication 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Objective

People with mental disorders frequently suffer from deficits in the ability to infer other’s mental states (Theory of Mind; ToM). Individuals with borderline personality disorder (BPD) show ToM deficits characterized by exceeding ToM (over-attributions of mental states). The present study analyzed associations between ToM, BPD severity, and depression severity in patients with BPD and other personality disorders.

Method

We analyzed ToM abilities in 128 patients with BPD and 82 patients with ‘mixed and other personality disorders’ (MOPD). MOPD are diagnosed if symptoms of multiple personality disorders are present without any set of symptoms being dominant enough to allow a specific diagnosis. We used the movies for the assessment of social cognition (MASC) to measure ToM abilities, the Patient Health Questionnaire (PHQ-9) to assess severity of depression and the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) to assess the severity of BPD symptoms.

Results

Both symptoms of BPD and depression were associated with exceeding ToM in separate regressions. Using a stepwise regression, only the association of depression severity with exceeding ToM was reliable. Patients with BPD and MOPD did not differ in exceeding ToM. Age was most reliably associated with ToM.

Conclusion

The results imply that exceeding ToM is associated with general psychopathology instead of BPD-symptoms in specific. Patients with MOPD show deficits similar to BPD patients.

Keywords

Borderline personality disorder
Theory of Mind
Depression
Mixed personality disorders
Symptom severity
http://dx.doi.org/10.13039/100020344 Gesellschaft für Forschungsförderung Niederösterreich issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2023
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pmcIntroduction

The Theory of Mind (ToM) refers to the ability to ascribe internal states, such as desires, beliefs, intentions, and emotions, to others and to explain and predict behavior on the basis of these mental states [13, 37]. A recent review of meta-analyses supported the association between mental disorders and ToM impairments by showing ToM deficits across 30 clinical conditions [13]. The Research Domain Criteria framework (RDoc; [35, 36]), which seeks to describe mental disorders in terms of their underlying impairment rather than by distinct categorical diagnoses, suggested ToM (i.e., understanding mental states of others) as a likely transdiagnostic factor by which mental health should be described.

ToM is part of a wide array of social cognition processes, which refer to the mental operations that underlie social interactions [13]. Social cognition refers to the processes by which humans perceive, interpret, and respond to social stimuli within their specific context [3, 11, 14]. Understanding other’s intentions, beliefs, and emotions (i.e., ToM) is crucial for socially adequate responses [32, 50] and successful social functioning [46]. Hence, ToM impairments can result in poor social adjustment [1].

Irrespective of the substantial evidence for ToM deficits in mental disorders (e.g., [13]), evidence regarding ToM among patients with personality disorders is relatively limited with the exception of borderline personality disorder (BPD). BPD is characterized by difficulties in social and interpersonal interactions [2, 29]. There is ample evidence that people with BPD suffer from ToM impairments compared to healthy controls [9, 19, 37, 44]. Importantly, ToM impairments can take on different forms; ToM deficits in BPD patients are typically marked by a tendency to ascribe extreme mental states to others [49]. This is often referred to as exceeding ToM or hypermentalising. This tendency involves drawing inferences from behavior that others would not find justified. In contrast, other disorders are more typically associated with reduced ToM (for instance alcohol use disorder; [41]), which implies a lower chance to ascribed mental states to others.

A recent meta-analysis challenged the idea that exceeding ToM was specific to BPD [34]. The meta-analysis concluded that exceeding ToM was found in a broad range of mental disorders (e.g., schizophrenia, autism spectrum disorder and persistent somatoform pain disorder). This meta-analysis reviewed associations between psychopathology and exceeding ToM and concluded that the association between exceeding ToM and psychopathology did not differ between BPD and other disorders. Thus, exceeding ToM was associated with general psychopathology. However, the applicability of this conclusion to personality disorders is limited, as only one study with a personality disorder other than BPD was included. This study did not find evidence for a significant association between psychopathology and exceeding ToM among individuals with antisocial personality disorder ([38] see [34]).

Further, McLaren and colleagues [34] only reviewed psychopathology directly related to the diagnosis, for instance they analyzed the effect of BPD-symptom severity in BPD patients. However, other symptoms could also affect ToM; only few studies have explored this question. There are, however, studies related to comorbidity of BPD and depression. These studies showed mixed results. A previous meta-analysis found that patients with major depressive disorder (MDD) had more ToM deficits than patients with BPD alone, patients with BPD and comorbid MDD actually had a better ToM than those who solely suffered from BPD or MDD [44]. In contrast, a later study could not replicate this finding. Instead, results showed that BPD patients with MDD had lower ToM abilities than BPD patients without MDD [57]. Thus, findings regarding the effect of comorbid depression on ToM abilities in BPD are contradictory.

A recent study by Normann-Eide and colleagues [40] found that severity of personality psychopathology and general severity of symptom distress were associated with exceeding ToM, in both patients with BPD and other personality disorders (OPD). Thus, the severity of psychopathology was associated to exceeding ToM in all patients and not limited to BPD patients. The study concluded that, general symptom distress might be more relevant to exceeding ToM than specific symptoms of personality disorders.

The interpretation of the ToM literature is complicated by the fact that many studies use the Reading the Mind in the Eyes Test (RMET; [6]) to measure ToM. This test does not fulfill all criteria for a ToM test and should therefore not be used to assess ToM. ToM measures require participants to represent other’s mental states as well as to distinguish between their own and the other’s mental state [43]. A test that fulfills these criteria is the Movies for the Assessment of Social Cognition (MASC; [15]), which, measures more complex ToM abilities than the RMET [43]. The MASC is considered to be a relatively ecological valid task [34], it presents videos of social interactions close to real life encounters. Further, the task assesses two different ToM aspects, that is the affective and the cognitive ToM [33, 57]. Cognitive ToM involves representing thoughts, intentions, or beliefs. Affective ToM involves representing feelings. The MASC includes items about both affective and cognitive mental states, which assures a more complete ToM assessment.

The current study investigated ToM abilities in patients with personality disorders using the ecologically valid MASC. First, we tested whether exceeding ToM errors were also prevalent in personality disorders other than BPD. Second, in line with McLaren and colleagues [34] we expected that exceeding ToM would be associated with psychopathology. Third, we explored whether BPD-symptom severity or depression severity were associated to ToM. Previous evidence suggested that ToM abilities are influenced by biological sex and age; healthy women show better ToM performance than men [4, 5] and ToM performance declines with increasing age among healthy adults [20]. We therefore controlled for sex and age. To strengthen the validity of the results we used a big and thus, highly powered sample.

Materials and methods

Participants and design

The study analyzed data from 210 patients (158 women, 52 men) from an inpatient treatment unit for personality disorders. Patients’ age ranged from 19 to 61 years, with an average age of 33.56 years (SD = 10.42). The sample included 128 patients treated for BPD (F60.3) and 82 patients treated for mixed and other personality disorders (MOPD; F61). The MOPD diagnosis was based on the International Classification of Diseases 10 (ICD-10) [55]. A mixed personality disorder is diagnosed if symptoms of multiple specific personality disorders according to F60 are present but no set of symptoms is dominant enough to allow a specific diagnosis [55].

Table 1 compares demographic characteristics of the two patient groups. There were more women among patients diagnosed with BPD than among patients diagnosed with MOPD. Unsurprisingly, patients diagnosed with BDP reported more symptoms of BPD than patients diagnosed with MOPD. BPD patients were younger and had a lower education level than MOPD patients. The BPD and MOPD patients were comparable regarding marital status and symptoms of depression. Table 1 Sociodemographic and clinical variables of patients diagnosed with BPD and MOPD

	BPD diagnosis

N = 128

N (%)

	MOPD diagnosis

N = 82

N (%)

	Χ2 (df)	p	
Sex			41.66 (1)	 < .001	
 Men	12 (9.4)	40 (48.8)			
 Women	116 (90.6)	42 (51.2)			
Education level			9.39 (1)	.002	
 Low education	88 (68.8)	39 (47.6)			
 Medium / high education	40 (25.0)	43 (37.8)			
Marital status	128 (61.0)	82 (39.1)	5.66 (2)	.912	
 Single	81 (63.3)	52 (63.4)			
 Married / in a relationship	35 (27.3)	21 (25.6)			
 Divorced / separated / widowed	12 (9.4)	9 (11.0)			
Comorbiditiesa	
 Neurotic, stress-related and somatoform disorders (F40-F48)	39.8%	30.5%			
 Mood disorders (F30-F39)	18.8%	24.4%			
 Eating disorders (F50)	13.3%	7.3%			
 Hyperkinetic disorders (F90)	10.2%	4.9%			
 Disorders of adult personality and behavior (F60-F69;	7.8%	8.5%			
	M (SD)	M (SD)	t (df)	p	
Age	30.30 (8.86)	38.66 (10.68)	6.16 (208)	 < .001	
Depression (PHQ-9)	16.37 (5.76)	15.09 (5.32)	-1.62 (208)	.107	
BPD symptoms (MSI-BPD)	7.54 (2.38)d	6.35 (2.43)e	-3.54 (205)	 < .001	
BPD Borderline personality disorder, MOPD Mixed and other personality disorders

aSorted by frequency in BPD group

b21 missing values

c4 missing values

d2 missing values

e1 missing values

Comorbidities were common among both patient groups. Among patients diagnosed with BPD 70.1% received at least one secondary diagnosis. Among patients diagnosed with MOPD 65.9% received at least one secondary diagnosis. Some patients received up to four secondary diagnoses. The frequency of common secondary diagnoses is described in Table 1. The most frequent secondary diagnoses were neurotic, stress-related and somatoform disorders (F40-F48; 39.8% among patients diagnosed with BPD and 30.5% among patients diagnosed with MOPD). This includes posttraumatic stress disorders, dissociative disorders, anxiety disorders and obsessive–compulsive disorders. The second most common comorbidity for patients diagnosed with BPD (18.8%) and for patients diagnosed with MOPD (24.4%) were mood disorders (F30-F39), which includes for example major depressive disorders and persistent mood disorders. The third and fourth most frequent diagnoses among patients diagnosed with BPD were eating disorders (F50; 13.3%) and hyperkinetic disorders (F90; 10.8%), which refers mainly to attention deficit hyperactivity disorder (ADHD). Among patients diagnosed with MOPD the third most frequent diagnoses were disorders of adult personality and behavior (F60-F69; 8.5%).

A post hoc power analysis with G*Power [16] confirmed the high power of the sample. The conducted regressions with 5 predictors had a power of > 0.99 to find a medium effect of f2 = 0.23 (equals Cohen’s d = 0.46) if it existed. The medium effects size reflects the estimated effect size for MASC studies previously reported in a meta-analysis of ToM deficits in BPD patients [37].

The study analyzed data that was collected as part of the routine examination at a university hospital for psychosomatic medicine in Austria. All patients of the specialized treatment unit were eligible if they were eighteen or older. The clinic treats patients that are able to participate in talk therapies. This means they needed to have at least conversational skills in German. Patients with acute psychotic symptoms, suicidal behavior, or acute intoxication are not admitted (for more details see [24]). Patients are typically referred to treatment by psychiatrists or other medical professionals. The hospitalization lasts between 8 to 12 weeks, during which the patients receive intense and disorder-specific therapy by an interdisciplinary team.

Procedure

The data was collected between July 2017 and August 2020 as part of the routine inpatient clinical care in a psychiatric-psychosomatic hospital. Only data from the assessment at intake were analyzed. Basic sociodemographic data, such as age and sex, were obtained from the hospital information system. Symptoms of BPD, depression and ToM were measured using the Computer-based Health Evaluation System [21]. Patients answered the questionnaires in a computer assessment room with up to seven other patients in separated cubicles. The assessment at intake took 2 h, divided in two 1-h sessions. The psychiatric diagnosis was determined within an unstandardized clinical interview.

Assessment

BPD symptoms

BPD symptoms were measured with the German version of the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). It’s a 10-item measure that assesses symptoms of borderline personality disorder (e.g., “Have any of your closest relationships been troubled by a lot of arguments and repeated breakups?”, “Have you been extremely moody?”, “Have you deliberately hurt yourself physically?”, [58]). Answers are given in a yes /no format. The number of yes answers represents the borderline symptom score. It can range from 0 to 10. Higher scores indicate stronger BPD symptoms. Previous research has suggested that a useful clinical cutoff score to predict BPD among adults is 7 or higher [42]. The MSI-BPD previously showed good psychometric properties, with good internal consistency (α = 0.74), test-retest reliability (rs = 0.72), good validity and good diagnostic accuracy [10, 39, 42, 58]. The German version performed equally well [27, 28].

Theory of Mind performance

The Movie for the assessment of social cognition (MASC) was used to assess ToM [15]. The MASC uses a 15-min movie divided into 45 short video clips showing social interactions between four actors (two women, two men) getting together for a dinner party. After each video clip the program asks participants about the characters’ feelings/emotions or thoughts/intentions. Questions appear on the screen together with four alternative answers. Each answer represents one of four response types: 1. Correct answer (i.e., accurate identification of characters’ feeling, emotion, thought, or intention), 2. Exceeding ToM (i.e., over-interpretative ToM or overmentalization), 3. Reduced ToM (i.e., insufficient ToM or undermentalization) and 4. No of ToM (i.e., complete lack of ToM or literal understanding). A total MASC score (max. score = 45) was calculated based on the number of correct answers. The number of each type of error, exceeding ToM, reduced ToM, and no ToM, was calculated. Beyond the 45 test questions, the MASC also includes six control questions related to physical events, with a respective set of answers representative of non-social inferences. The MASC has previously shown high reliability, internal consistency (α ≥ 0.82 for all scores), good test-retest stability and good convergent and discriminant validity [15, 17, 45].

Depression

Symptoms of depression were assessed with the German version of the depression module of the Patient Health Questionnaire (PHQ-9; [25]). Nine items related to DSM-IV criteria assessed the severity of depression symptoms (e.g., “Little interest or pleasure in doing things”,“Felling down, depressed, or hopeless”; “Feeling tired or having little energy”). Participants rated how often they were bothered by each symptom within the last 2 weeks on a scale from 0 (not at all) to 3 (nearly every day). Ratings are summed to a total severity score ranging from 0 to 27. Major depressive disorder (MDD) should be considered in patients who endorse ≥ 5 of the 9 symptoms as present “more than half the days” (the 9th item, “Thoughts that you would be better off dead or of hurting yourself in some way”, counts if endorsed as present on “several days”) and one of the first two symptoms (depressed mood or loss of interest) is endorsed. The PHQ-9 previously showed good psychometric properties, with high internal consistency (α = 0.86) and good test–retest reliability (r = 0.84), good convergent and discriminant validity, and good sensitivity to change [7, 26, 30, 30, 31, 31]. The German version of the PHQ-9 showed similarly good psychometric properties [18].

Diagnoses

The psychiatric diagnosis refers to the main diagnoses, which was given by a psychiatrist (coded with “1” for BPD diagnosis and “0” for MOPD) as part of the standard clinical routine. The diagnosis was based on ICD-10 and was derived within a clinical interview upon intake by integrating written and oral symptom reports by patients, and information about their medical history. None of the questionnaires described above were used to give diagnoses.

Sociodemographic data

Sex, age, and education level were derived from the hospital information system. Sex (male, female) is defined in terms of self-reported biological sex. Age refers to the chronological age (in years) at the time of admission. Education level was classified into two categories: “1” for no school-leaving qualification or compulsory school, “2” for secondary school and college degrees.

Statistical analysis

First, we compared demographic variables, symptoms, and ToM between BPD and MOPD patients using Χ2 or t-tests. Afterwards, we conducted four sets of linear regressions. Each set of regressions used one of four (continuous) ToM outcomes as dependent variables. These four ToM outcomes were overall ToM performance and the frequencies of one of the three error types (exceeding ToM, reduced ToM, no ToM). The first set of regressions tested the association of ToM with BPD severity, while controlling for age, sex, and psychiatric diagnosis (BPD vs. MOPD). Thus, BPD severity, psychiatric diagnosis (BPD vs. MOPD), age, and sex were simultaneously entered as predictors for each of the four ToM outcomes. The second set of regressions exchanged BPD severity with depression severity and was otherwise identical. The third set of regressions entered both BPD severity and depression severity, as well as the control variables psychiatric diagnosis (BPD vs. MOPD), age, and sex. Since this set did not reach a conclusive result, we repeated the third set of regressions with stepwise inclusions of the same predictors. All analyses were computed using IBM SPSS (Version 27).

Results

Table 2 presents the unadjusted differences in MASC performance between BPD and MOPD patients. BPD patients showed an overall better MASC performance than MOPD patients. This difference resulted from BPD patients making fewer reduced ToM errors. Table 2 ToM in patients diagnosed with BPD and MOPD in the “Movie for the Assessment of Social Cognition” (MASC)

	BPD diagnosis
M (SD)	MOPD diagnosis
M (SD)	F (df)	P	ηp2	
MASC total correct	31.41 (5.64)	29.54 (6.54)	4.84 (1, 208)	.029	0.023	
MASC exceeding ToM	7.52 (3.75)	7.23 (3.45)	0.30 (1, 208)	.582	0.001	
MASC reduced ToM	6.04 (2.91)	6.99 (2.90)	5.34 (1, 208)	.022	0.025	
MASC no ToM	2.94 (2.03)	3.27 (2.65)	1.04 (1, 208)	.309	0.005	
BPD Borderline personality disorder, MOPD Mixed and other personality disorders, ToM Theory of Mind

Regression results are presented in Tables 3 and 4. The first set of regressions (Regression 1, Table 3 and 4) tested associations between BPD-symptom severity and ToM. The regression showed that the severity of BPD was associated with exceeding ToM, while psychiatric diagnosis (MOPD and BPD) showed no such association. Table 3 Regressions of diagnosis, BPD severity, depression severity, sex, and age on ToM total correct responses and exceeding ToM errors

	ToM total	exceeding ToM	
Predictors	β	B	CI 95%	β	B	CI 95%	
Regression 1 (enter)							
 Sex

 (0 = female, 1 = male)

	-0.03	-0.37	[-2.49, 1.74]	0.16	1.31	[0.00, 2.62]	
 Age in years	-0.23	-0.13	[-0.22, -0.05]	0.00	0.00	[-0.05, 0.05]	
 BPD severity	-0.10	-0.25	[-0.59, 0.08]	0.16	0.23	[0.02, 0.44]	
 BPD vs. MOPD diagnosis	0.10	1.18	[-0.74, 3.11]	0.06	0.43	[-0.76, 1.61]	
Regression 2 (enter)							
 Sex

 (0 = female, 1 = male)

	-0.02	-0.22	[-2.35, 1.90]	0.17	1.39	[0.09, 2.68]	
 Age in years	-0.21	-0.12	[-0.21, -0.04]	-0.01	-0.00	[-0.06, 0.05]	
 Depression severity	-0.14	-0.15	[-0.29, -0.01]	0.18	0.12	[0.03, 0.21]	
 BPD vs. MOPD diagnosis	0.08	0.95	[-0.96, 2.86]	0.09	0.65	[-0.51, 1.81]	
Regression 3 (enter)							
 Sex

 (0 = female, 1 = male)

	-0.02	-0.34	[-2.45, 1.77]	0.15	1.29	[-0.01, 2.59]	
 Age in years	-0.22	-0.12	[-0.21, -0.04]	-0.02	-0.01	[-0.06, 0.05]	
 BPD severity	-0.05	-0.13	[-0.49, 0.24]	0.10	0.15	[-0.07, 0.38]	
 Depression severity	-0.13	-0.14	[-0.29, 0.02]	0.13	0.08	[-0.01, 0.18]	
 BPD vs. MOPD diagnosis	0.10	1.28	[-0.64, 3.20]	0.05	0.37	[-0.82, 1.55]	
Regression 4 (stepwise)							
 Age in years	-0.26	-0.15	[-0.23, -0.07]	not included	
 Depression severity	-0.13	-0.14	[-0.28, -0.003]	0.17	0.11	[0.02, 0.20]	
Note. BPD borderline personality disorder, MOPD mixed and other personality disorders, ToM Theory of Mind, CI 95% 95% confidence interval; bold numbers are significant on a p = .05 level

Table 4 Regressions of diagnosis, BPD severity, depression severity, sex, and age on reduced and no ToM errors

	reduced ToM	no ToM	
Predictors	β	B	CI 95%	β	B	CI 95%	
Regression 1 (enter)							
 Sex

 (0 = female, 1 = male)

	-0.06	-0.38	[-1.42, 0.67]	-0.10	-0.52	[-1.30, 0.26]	
 Age in years	0.23	0.07	[0.02, 0.11]	0.18	0.04	[0.01, 0.07]	
 BPD severity	-0.01	-0.01	[-0.17, 0.16]	0.01	0.01	[-0.11, 0.14]	
 BPD vs. MOPD diagnosis	-0.10	-0.62	[-1.57, 0.33]	-0.08	-0.37	[-1.08, 0.34]	
Regression 2 (enter)							
 Sex

 (0 = female, 1 = male)

	-0.07	-0.46	[-1.50, 0.58]	-0.11	-0.61	[-1.44, 0.22]	
 Age in years	0.22	0.06	[0.02, 0.10]	0.16	0.04	[0.00, 0.07]	
 Depression severity	0.03	0.02	[-0.05, 0.09]	0.03	0.01	[-0.04, 0.07]	
 BPD vs. MOPD diagnosis	-0.11	-0.64	[-1.57, 0.30]	-0.06	-0.29	[-1.04, 0.45]	
Regression 3 (enter)							
 Sex

 (0 = female, 1 = male)

	-0.06	-0.38	[-1.43, 0.66]	-0.10	-0.52	[-1.31, 0.26]	
 Age in years	0.22	0.06	[0.02, 0.11]	0.18	0.04	[0.005, 0.07]	
 BPD severity	-0.03	-0.04	[-0.22, 0.15]	-0.01	-0.01	[-0.15, 0.13]	
 Depression severity	0.06	0.03	[-0.05, 0.11]	0.06	0.02	[-0.04, 0.08]	
 BPD vs. MOPD diagnosis	-0.11	-0.64	[-1.59, 0.31]	-0.09	-0.38	[-1.09, 0.33]	
Regression 4 (stepwise)							
 Age in years	0.25	0.07	[0.03, 0.11]	0.18	0.04	[0.01, 0.06]	
Note. BPD borderline personality disorder, MOPD mixed and other personality disorders, ToM Theory of Mind, CI 95% 95% confidence interval; bold numbers are significant on a p = .05 level

The second set of regressions (Regression 2, Tables 3 and 4) tested for effects of depression severity instead of BPD severity. Equal to BPD severity depression severity was associated with exceeding ToM. In addition, depression severity was associated with lower overall ToM performance. A Pearson correlation showed that BPD severity and depression severity were moderately correlated, r = 0.42.

The third set of regressions (Regression 3, Tables 3 and 4) tested BPD severity and depression severity simultaneously, which did not yield significant associations of either psychopathology with ToM. The last set of regressions instead tested the same predictors stepwise. In these analyses depression severity was associated with overall ToM and exceeding ToM.

Age affected the overall ToM, as well as reduced and no ToM errors; younger patients performed better than older patients. There was no significant effect of age on exceeding ToM. Men made more exceeding ToM errors than women. This effect was not reliable in the stepwise regression. Otherwise, sex did not affect results.

Discussion

The present study found that ToM was associated with both the severity of symptoms of depression and symptoms of BPD in patients with personality disorders. This association was driven by exceeding ToM errors, which were more prevalent in patients with more severe psychopathology. Exceeding ToM implies that behaviors are over-interpreted in a way that ascribe intentions where others would not. The association between exceeding ToM and psychopathology was driven by the severity of depression and not BPD-symptom severity. Other ToM errors (i.e., reduced ToM and no ToM) showed no association with symptom severity. The psychiatric diagnosis of BPD or MOPD was not associated with exceeding ToM.

Previous research has established that BPD patients are likely to show exceeding ToM compared to healthy controls [19, 37]. Further, the results support the notion that exceeding ToM is associated with psychopathology in general [34]. The current study expands this association between psychopathology and exceeding to patients with the diagnosis of mixed and other personality disorders. Interestingly, the results show that depression severity is more reliably associated with exceeding ToM than severity of BPD symptoms. This supports the idea that general psychopathology is associated with exceeding ToM rather than BPD symptoms specifically. This further supports the transdiagnostic nature of ToM (RDoc; [35, 36]) and its deficits since it is less clearly related to symptoms specific to BDP.

The current results did not find differences between BPD and MOPD patients regarding exceeding ToM. In contrast, a previous study had found that BDP patients more frequently showed excessive ToM than patients with other personality disorders [40]. The study by Normann-Eide and colleagues [40] showed that when differences in severity of pathology and differences in criteria of personality disorders were accounted for, the diagnoses no longer predicted exceeding ToM. Similarly, the current study showed that BPD severity and depression severity were better predictors of ToM abilities than diagnoses. However, the current study did not account for severity of other personality disorders. Both studies relied on the MASC to measure ToM. A different study found that ToM deficits were specific to BPD relative to other personality disorders even when general symptom distress was controlled for [48]. This study relied on an interview using autobiographical memories to measure ToM. Interestingly, the meta-analysis by McLaren and colleagues [34] suggested that it is important to test whether exceeding ToM deficits would be more pronounced among BPD patients if the measure would have personal relevance and emotional salience, which are suspected to increase ToM deficits among BPD patients.

Our findings complement results on the association of depression and ToM. Symptoms of depression were associated with exceeding ToM and lower overall ToM performance. This is in line with a study by Zabihzadeh and colleguage [57], which found that BPD patients with MDD had lower ToM abilities than those without MDD. However, in contrast to our study previous studies had shown that depressed patients made more reduced ToM errors than HC [54], which we cannot test without a health control group. In contrast to our findings that showed increased depression symptoms among BPD patients were associated with a higher rate of exceeding ToM errors, a meta-analysis by Richman and Unoka [44] found that ToM performance increased among patients with a combination of BPD and depression. However, these findings relied on different measures; ToM results are influenced by the type of measure used [43].

The current findings suggest that patients with personality disorders and severe symptoms of depression are at a high risk of ToM impairment and might therefore have an increased need for ToM skills trainings. Multiple treatments of mental illness focus on the improvement of social cognition skills [23, 52]. They were efficient in both patients with depression [22] and BPD [47]. It should be tested whether these treatments are beneficial to patients with personality disorders and severe depression.

Earlier effects of age on ToM could be replicated [20]. ToM abilities were higher among younger patients than older patients. This is in line with a meta-analysis showing more ToM errors among older individuals [20]. Only exceeding ToM was not significantly related to age. In line with previous findings, which showed that women perform better than men on ToM measures [4, 5], men made more exceeding ToM errors then women. However, this association was not reliable in the stepwise regression and contradicts the findings of a previous meta-analysis on ToM in BPD patients, which did not find an effect of sex-ratio on ToM [37].

A limitation of the study is that it did not assess the severity of other personality disorders. This limits our ability to test the association with other personality disorders and exceeding ToM. The mixed and other personality disorders category combines a multitude of possible symptoms. Explicit coding of the different personality disorder criteria would have allowed more detailed analyses. Further, the current study used a short measure of BPD symptoms meant for screening [58]. Future studies should replicate this findings with more thorough measures of BPD symptoms such as the Borderline Symptom List (BSL; [8]). Another shortcoming of the current study is, that it analyzed psychiatric diagnoses based on the ICD-10 determined within the clinical routine and without a standardized structured clinical interview. While diagnoses in previous research are predominantly based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) measured by the Structured Clinical Interview for DSM-IV Axis II (SCID-II; [37, 53]). However, ICD diagnoses are commonly used in Europe and mandatory for billing, further, they typically become the basis for treatment recommendations. Therefore, the finding that ICD-10 diagnoses asses within an unstandardized interview were not associated with ToM have high practical relevance. The finding supports the need for standardized measures in clinical care. Another limitation of the present study is the absence of healthy participants. It is unclear whether the association between BPD severity and ToM would generalize to the general population since BPD symptoms are much more prevalent in clinical samples [12]. Further, without a healthy control it remains unclear whether the BPD and MOPD groups show ToM deficits. However, descriptively patients diagnosed with BPD within the current sample performed worse on the MASC than BPD patients within previous samples [3, 40, 51]. This makes it likely that the current results indicate ToM deficits.

Conclusion

In the current study, overall ToM performance was not found to differ between patients with BPD and MOPD when age and gender were considered. Exceeding ToM increased with both higher BPD-symptom severity and depression severity in individuals with BPD and MOPD diagnoses. Depression severity was more reliably associated with exceeding ToM than BPD-symptom severity. Thus, general psychopathology was a stronger predictor of ToM deficits than BPD-specific symptoms.

Acknowledgements

We acknowledge support by Open Access Publishing Fund of Karl Landsteiner University of Health Sciences, Krems, Austria.

Authors’ contributions

JB and MS designed and conceptualized the study. MS assured the data access. JB conducted the data curation and data analyses. MS prepared the first draft of the introduction and discussion sections. JB, MK and SG thoroughly revised them. SG drafted the method and result sections. JB, MS, SG, and MK revised the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

The Gesellschaft für Forschungsförderung Niederösterreich (GFF) [Society for Research Promotion Lower Austria a] supported this research by financing the endowed professorship in clinical psychology held by MS. The Open Access Publishing Fund of Karl Landsteiner University of Health Sciences, Krems, Austria supports the publication of this manuscript. The VAMED Institute for Gender Medicine financed the position held by JB. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Availability of data and materials

The datasets presented in this article are not readily available because of the vulnerability of the study sample. Participants of this study did not agree for their data to be shared publicly, so supporting data is not available.

Declarations

Ethics approval and consent to participate

The study retrospectively analyzed data collected within routine clinical care. All participants consented to the use of their data. The analysis was approved by the ethics commission of the Karl Landsteiner University of Health Sciences (Nr: 1020/2021) and complies with the ethical standards of the Declaration of Helsinki [56].

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

The original version of this article was revised: Tables 3 and 4 were published incorrectly.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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References

1. Adegboye D Sterr A Lin J-P Owen TJ Theory of mind, emotional and social functioning, and motor severity in children and adolescents with dystonic cerebral palsy Eur J Paediatr Neurol 2017 21 3 549 556 10.1016/j.ejpn.2017.01.013 28237421
Adegboye D, Sterr A, Lin J-P, Owen TJ. Theory of mind, emotional and social functioning, and motor severity in children and adolescents with dystonic cerebral palsy. Eur J Paediatr Neurol. 2017;21(3):549–56. 10.1016/j.ejpn.2017.01.013.28237421 10.1016/j.ejpn.2017.01.013
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association; 2013. 10.1176/appi.books.9780890425596.
3. Andreou C Kelm L Bierbrodt J Braun V Lipp M Yassari AH Moritz S Factors contributing to social cognition impairment in borderline personality disorder and schizophrenia Psychiatry Res 2015 229 3 872 879 10.1016/j.psychres.2015.07.057 26257087
Andreou C, Kelm L, Bierbrodt J, Braun V, Lipp M, Yassari AH, Moritz S. Factors contributing to social cognition impairment in borderline personality disorder and schizophrenia. Psychiatry Res. 2015;229(3):872–9. 10.1016/j.psychres.2015.07.057.26257087 10.1016/j.psychres.2015.07.057
4. Baron-Cohen S The extreme male brain theory of autism Trends Cogn Sci 2002 6 6 248 254 10.1016/S1364-6613(02)01904-6 12039606
Baron-Cohen S. The extreme male brain theory of autism. Trends Cogn Sci. 2002;6(6):248–54. 10.1016/S1364-6613(02)01904-6.12039606 10.1016/S1364-6613(02)01904-6
5. Baron-Cohen S Bowen DC Holt RJ Allison C Auyeung B Lombardo MV Smith P Lai M-C The “Reading the Mind in the Eyes” Test: complete absence of typical sex difference in ~400 men and women with autism PLoS One 2015 10 8 e0136521 10.1371/journal.pone.0136521 26313946
Baron-Cohen S, Bowen DC, Holt RJ, Allison C, Auyeung B, Lombardo MV, Smith P, Lai M-C. The “Reading the Mind in the Eyes” Test: complete absence of typical sex difference in ~400 men and women with autism. PLoS One. 2015;10(8):e0136521. 10.1371/journal.pone.0136521.26313946 10.1371/journal.pone.0136521
6. Baron-Cohen S Wheelwright S Hill J Raste Y Plumb I The “Reading the Mind in the Eyes” Test revised version: a study with normal adults, and adults with asperger syndrome or high-functioning autism J Child Psychol Psychiatry 2001 42 2 241 251 10.1111/1469-7610.00715 11280420
Baron-Cohen S, Wheelwright S, Hill J, Raste Y, Plumb I. The “Reading the Mind in the Eyes” Test revised version: a study with normal adults, and adults with asperger syndrome or high-functioning autism. J Child Psychol Psychiatry. 2001;42(2):241–51. 10.1111/1469-7610.00715.11280420 10.1111/1469-7610.00715
7. Beard C Hsu KJ Rifkin LS Busch AB Björgvinsson T Validation of the PHQ-9 in a psychiatric sample J Affect Disord 2016 193 267 273 10.1016/j.jad.2015.12.075 26774513
Beard C, Hsu KJ, Rifkin LS, Busch AB, Björgvinsson T. Validation of the PHQ-9 in a psychiatric sample. J Affect Disord. 2016;193:267–73. 10.1016/j.jad.2015.12.075.26774513 10.1016/j.jad.2015.12.075
8. Bohus M Limberger MF Frank U Chapman AL Kühler T Stieglitz R-D Psychometric properties of the borderline symptom list (BSL) Psychopathology 2007 40 2 126 132 10.1159/000098493 17215599
Bohus M, Limberger MF, Frank U, Chapman AL, Kühler T, Stieglitz R-D. Psychometric properties of the borderline symptom list (BSL). Psychopathology. 2007;40(2):126–32. 10.1159/000098493.17215599 10.1159/000098493
9. Bora E A meta-analysis of theory of mind and ‘mentalization’ in borderline personality disorder: a true neuro-social-cognitive or meta-social-cognitive impairment? Psychol Med 2021 51 15 2541 2551 10.1017/S0033291721003718 34530941
Bora E. A meta-analysis of theory of mind and ‘mentalization’ in borderline personality disorder: a true neuro-social-cognitive or meta-social-cognitive impairment? Psychol Med. 2021;51(15):2541–51. 10.1017/S0033291721003718.34530941 10.1017/S0033291721003718
10. Chanen AM Jovev M Djaja D McDougall E Yuen HP Rawlings D Jackson HJ Screening for borderline personality disorder in outpatient youth J Pers Disord 2008 22 4 353 364 10.1521/pedi.2008.22.4.353 18684049
Chanen AM, Jovev M, Djaja D, McDougall E, Yuen HP, Rawlings D, Jackson HJ. Screening for borderline personality disorder in outpatient youth. J Pers Disord. 2008;22(4):353–64. 10.1521/pedi.2008.22.4.353.18684049 10.1521/pedi.2008.22.4.353
11. Chung YS Mathews JR Barch DM The effect of context processing on different aspects of social cognition in schizophrenia Schizophr Bull 2011 37 5 1048 1056 10.1093/schbul/sbq012 20185539
Chung YS, Mathews JR, Barch DM. The effect of context processing on different aspects of social cognition in schizophrenia. Schizophr Bull. 2011;37(5):1048–56. 10.1093/schbul/sbq012.20185539 10.1093/schbul/sbq012
12. Comtois KA Carmel A Borderline personality disorder and high utilization of inpatient psychiatric hospitalization: concordance between research and clinical diagnosis J Behav Health Serv Res 2016 43 2 272 280 10.1007/s11414-014-9416-9 24875431
Comtois KA, Carmel A. Borderline personality disorder and high utilization of inpatient psychiatric hospitalization: concordance between research and clinical diagnosis. J Behav Health Serv Res. 2016;43(2):272–80. 10.1007/s11414-014-9416-9.24875431 10.1007/s11414-014-9416-9
13. Cotter J Granger K Backx R Hobbs M Looi CY Barnett JH Social cognitive dysfunction as a clinical marker: a systematic review of meta-analyses across 30 clinical conditions Neurosci Biobehav Rev 2018 84 92 99 10.1016/j.neubiorev.2017.11.014 29175518
Cotter J, Granger K, Backx R, Hobbs M, Looi CY, Barnett JH. Social cognitive dysfunction as a clinical marker: a systematic review of meta-analyses across 30 clinical conditions. Neurosci Biobehav Rev. 2018;84:92–9. 10.1016/j.neubiorev.2017.11.014.29175518 10.1016/j.neubiorev.2017.11.014
14. Dekker TEG van der Heijden HS Schirmbeck F van Amelsvoort T Bartels-Velthuis AA Simons CJP de Haan L Vermeulen JM The association between smoking behaviour, social cognition and social functioning in patients with a non-affective psychotic disorder: a prospective follow-up study Schizophr Res Cogn 2021 26 100206 10.1016/j.scog.2021.100206 34258239
Dekker TEG, van der Heijden HS, Schirmbeck F, van Amelsvoort T, Bartels-Velthuis AA, Simons CJP, de Haan L, Vermeulen JM. The association between smoking behaviour, social cognition and social functioning in patients with a non-affective psychotic disorder: a prospective follow-up study. Schizophr Res Cogn. 2021;26:100206. 10.1016/j.scog.2021.100206.34258239 10.1016/j.scog.2021.100206
15. Dziobek I Fleck S Kalbe E Rogers K Hassenstab J Brand M Kessler J Woike J Wolf O Convit A Introducing MASC: a movie for the assessment of social cognition J Autism Dev Disord 2006 36 623 636 10.1007/s10803-006-0107-0 16755332
Dziobek I, Fleck S, Kalbe E, Rogers K, Hassenstab J, Brand M, Kessler J, Woike J, Wolf O, Convit A. Introducing MASC: a movie for the assessment of social cognition. J Autism Dev Disord. 2006;36:623–36. 10.1007/s10803-006-0107-0.16755332 10.1007/s10803-006-0107-0
16. Faul F Erdfelder E Lang A-G Buchner A G* Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences Behav Res Methods 2007 39 2 175 191 10.3758/BF03193146 17695343
Faul F, Erdfelder E, Lang A-G, Buchner A. G* Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175–91. 10.3758/BF03193146.17695343 10.3758/BF03193146
17. Fossati A Borroni S Dziobek I Fonagy P Somma A Thinking about assessment: further evidence of the validity of the Movie for the Assessment of Social Cognition as a measure of mentalistic abilities Psychoanal Psychol 2018 35 1 127 141 10.1037/pap0000130
Fossati A, Borroni S, Dziobek I, Fonagy P, Somma A. Thinking about assessment: further evidence of the validity of the Movie for the Assessment of Social Cognition as a measure of mentalistic abilities. Psychoanal Psychol. 2018;35(1):127–41. 10.1037/pap0000130.10.1037/pap0000130
18. Gräfe K Zipfel S Herzog W Löwe B Screening psychischer Störungen mit dem “Gesundheitsfragebogen für Patienten (PHQ-D)“ Diagnostica 2004 50 4 171 181 10.1026/0012-1924.50.4.171
Gräfe K, Zipfel S, Herzog W, Löwe B. Screening psychischer Störungen mit dem “Gesundheitsfragebogen für Patienten (PHQ-D)“. Diagnostica. 2004;50(4):171–81. 10.1026/0012-1924.50.4.171.10.1026/0012-1924.50.4.171
19. Hanegraaf L van Baal S Hohwy J Verdejo-Garcia A A systematic review and meta-analysis of ‘Systems for Social Processes’ in borderline personality and substance use disorders Neurosci Biobehav Rev 2021 127 572 592 10.1016/j.neubiorev.2021.04.013 33865874
Hanegraaf L, van Baal S, Hohwy J, Verdejo-Garcia A. A systematic review and meta-analysis of ‘Systems for Social Processes’ in borderline personality and substance use disorders. Neurosci Biobehav Rev. 2021;127:572–92. 10.1016/j.neubiorev.2021.04.013.33865874 10.1016/j.neubiorev.2021.04.013
20. Henry JD Phillips LH Ruffman T Bailey PE A meta-analytic review of age differences in theory of mind Psychol Aging 2013 28 3 826 839 10.1037/a0030677 23276217
Henry JD, Phillips LH, Ruffman T, Bailey PE. A meta-analytic review of age differences in theory of mind. Psychol Aging. 2013;28(3):826–39. 10.1037/a0030677.23276217 10.1037/a0030677
21. Holzner B Giesinger JM Pinggera J Zugal S Schöpf F Oberguggenberger AS Gamper EM Zabernigg A Weber B Rumpold G The Computer-based Health Evaluation Software (CHES): a software for electronic patient-reported outcome monitoring BMC Med Inform Decis Mak 2012 12 1 126 10.1186/1472-6947-12-126 23140270
Holzner B, Giesinger JM, Pinggera J, Zugal S, Schöpf F, Oberguggenberger AS, Gamper EM, Zabernigg A, Weber B, Rumpold G. The Computer-based Health Evaluation Software (CHES): a software for electronic patient-reported outcome monitoring. BMC Med Inform Decis Mak. 2012;12(1):126. 10.1186/1472-6947-12-126.23140270 10.1186/1472-6947-12-126
22. Jelinek L Faissner M Moritz S Kriston L Long-term efficacy of Metacognitive Training for Depression (D-MCT): a randomized controlled trial Br J Clin Psychol 2019 58 3 245 259 10.1111/bjc.12213 30556583
Jelinek L, Faissner M, Moritz S, Kriston L. Long-term efficacy of Metacognitive Training for Depression (D-MCT): a randomized controlled trial. Br J Clin Psychol. 2019;58(3):245–59. 10.1111/bjc.12213.30556583 10.1111/bjc.12213
23. Jelinek L Hauschildt M Wittekind CE Schneider BC Kriston L Moritz S Efficacy of metacognitive training for depression: a randomized controlled trial Psychother Psychosom 2016 85 4 231 234 10.1159/000443699 27230865
Jelinek L, Hauschildt M, Wittekind CE, Schneider BC, Kriston L, Moritz S. Efficacy of metacognitive training for depression: a randomized controlled trial. Psychother Psychosom. 2016;85(4):231–4. 10.1159/000443699.27230865 10.1159/000443699
24. Knopp M Riffer F Burghardt J Sprung M Geschlechtsspezifische Unterschiede in der psychotherapeutischen Versorgung Psychotherapeut 2021 10.1007/s00278-021-00523-4
Knopp M, Riffer F, Burghardt J, Sprung M. Geschlechtsspezifische Unterschiede in der psychotherapeutischen Versorgung. Psychotherapeut. 2021. 10.1007/s00278-021-00523-4.10.1007/s00278-021-00523-4
25. Kroenke K Spitzer RL Williams JBW The PHQ-9 J Gen Intern Med 2001 16 9 606 613 10.1046/j.1525-1497.2001.016009606.x 11556941
Kroenke K, Spitzer RL, Williams JBW. The PHQ-9. J Gen Intern Med. 2001;16(9):606–13. 10.1046/j.1525-1497.2001.016009606.x.11556941 10.1046/j.1525-1497.2001.016009606.x
26. Kroenke K Spitzer RL Williams JBW Löwe B The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review Gen Hosp Psychiatry 2010 32 4 345 359 10.1016/j.genhosppsych.2010.03.006 20633738
Kroenke K, Spitzer RL, Williams JBW, Löwe B. The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345–59. 10.1016/j.genhosppsych.2010.03.006.20633738 10.1016/j.genhosppsych.2010.03.006
27. Kröger C Huget F Roepke S Diagnostische Effizienz des McLean Screening Instrument für Borderline-Persönlichkeitsstörung in einer Stichprobe, die eine stationäre, störungsspezifische Behandlung in Anspruch nehmen möchte Psychother Psych Med 2011 61 11 481 486 10.1055/s-0031-1291275
Kröger C, Huget F, Roepke S. Diagnostische Effizienz des McLean Screening Instrument für Borderline-Persönlichkeitsstörung in einer Stichprobe, die eine stationäre, störungsspezifische Behandlung in Anspruch nehmen möchte. Psychother Psych Med. 2011;61(11):481–6. 10.1055/s-0031-1291275.10.1055/s-0031-1291275
28. Kröger C Vonau M Kliem S Kosfelder J Screening-Instrument für die Borderline-Persönlichkeitsstörung. Diagnostische Effizienz der deutschen Version des McLean Screening Instrument for Borderline Personality Disorder Psychother Psych Med 2010 60 09/10 391 396 10.1055/s-0030-1248279
Kröger C, Vonau M, Kliem S, Kosfelder J. Screening-Instrument für die Borderline-Persönlichkeitsstörung. Diagnostische Effizienz der deutschen Version des McLean Screening Instrument for Borderline Personality Disorder. Psychother Psych Med. 2010;60(09/10):391–6. 10.1055/s-0030-1248279.10.1055/s-0030-1248279
29. Lazarus SA Cheavens JS Festa F Zachary Rosenthal M Interpersonal functioning in borderline personality disorder: a systematic review of behavioral and laboratory-based assessments Clin Psychol Rev 2014 34 3 193 205 10.1016/j.cpr.2014.01.007 24534643
Lazarus SA, Cheavens JS, Festa F, Zachary Rosenthal M. Interpersonal functioning in borderline personality disorder: a systematic review of behavioral and laboratory-based assessments. Clin Psychol Rev. 2014;34(3):193–205. 10.1016/j.cpr.2014.01.007.24534643 10.1016/j.cpr.2014.01.007
30. Löwe B Kroenke K Herzog W Gräfe K Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9) J Affect Disord 2004 81 1 61 66 10.1016/S0165-0327(03)00198-8 15183601
Löwe B, Kroenke K, Herzog W, Gräfe K. Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9). J Affect Disord. 2004;81(1):61–6.15183601 10.1016/S0165-0327(03)00198-8
31. Löwe B Spitzer RL Gräfe K Kroenke K Quenter A Zipfel S Buchholz C Witte S Herzog W Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians’ diagnoses J Affect Disord 2004 78 2 131 140 10.1016/S0165-0327(02)00237-9 14706723
Löwe B, Spitzer RL, Gräfe K, Kroenke K, Quenter A, Zipfel S, Buchholz C, Witte S, Herzog W. Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians’ diagnoses. J Affect Disord. 2004;78(2):131–40.14706723 10.1016/S0165-0327(02)00237-9
32. Luke N Banerjee R Differentiated associations between childhood maltreatment experiences and social understanding: a meta-analysis and systematic review Dev Rev 2013 33 1 1 28 10.1016/j.dr.2012.10.001
Luke N, Banerjee R. Differentiated associations between childhood maltreatment experiences and social understanding: a meta-analysis and systematic review. Dev Rev. 2013;33(1):1–28. 10.1016/j.dr.2012.10.001.10.1016/j.dr.2012.10.001
33. Maleki G Zabihzadeh A Richman MJ Demetrovics Z Mohammadnejad F Decoding and reasoning mental states in major depression and social anxiety disorder BMC Psychiatry 2020 20 1 463 10.1186/s12888-020-02873-w 32972392
Maleki G, Zabihzadeh A, Richman MJ, Demetrovics Z, Mohammadnejad F. Decoding and reasoning mental states in major depression and social anxiety disorder. BMC Psychiatry. 2020;20(1):463. 10.1186/s12888-020-02873-w.32972392 10.1186/s12888-020-02873-w
34. McLaren V Gallagher M Hopwood CJ Sharp C Hypermentalizing and borderline personality disorder: a meta-analytic review Am J Psychother 2022 75 1 21 31 10.1176/appi.psychotherapy.20210018 35099264
McLaren V, Gallagher M, Hopwood CJ, Sharp C. Hypermentalizing and borderline personality disorder: a meta-analytic review. Am J Psychother. 2022;75(1):21–31. 10.1176/appi.psychotherapy.20210018.35099264 10.1176/appi.psychotherapy.20210018
35. Michelini G Palumbo IM DeYoung CG Latzman RD Kotov R Linking RDoC and HiTOP: a new interface for advancing psychiatric nosology and neuroscience Clin Psychol Rev 2021 86 102025 10.1016/j.cpr.2021.102025 33798996
Michelini G, Palumbo IM, DeYoung CG, Latzman RD, Kotov R. Linking RDoC and HiTOP: a new interface for advancing psychiatric nosology and neuroscience. Clin Psychol Rev. 2021;86:102025. 10.1016/j.cpr.2021.102025.33798996 10.1016/j.cpr.2021.102025
36. National Institutes of Mental Health. NIMH » About RDoC. Research Domain Criteria (RDoC); 2020. https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/about-rdoc.shtml.
37. Németh N Mátrai P Hegyi P Czéh B Czopf L Hussain A Pammer J Szabó I Solymár M Kiss L Hartmann P Szilágyi ÁL Kiss Z Simon M Theory of mind disturbances in borderline personality disorder: a meta-analysis Psychiatry Res 2018 270 143 153 10.1016/j.psychres.2018.08.049 30248485
Németh N, Mátrai P, Hegyi P, Czéh B, Czopf L, Hussain A, Pammer J, Szabó I, Solymár M, Kiss L, Hartmann P, Szilágyi ÁL, Kiss Z, Simon M. Theory of mind disturbances in borderline personality disorder: a meta-analysis. Psychiatry Res. 2018;270:143–53. 10.1016/j.psychres.2018.08.049.30248485 10.1016/j.psychres.2018.08.049
38. Newbury-Helps J Feigenbaum J Fonagy P Offenders with antisocial personality disorder display more impairments in mentalizing J Pers Disord 2017 31 2 232 255 10.1521/pedi_2016_30_246 27064853
Newbury-Helps J, Feigenbaum J, Fonagy P. Offenders with antisocial personality disorder display more impairments in mentalizing. J Pers Disord. 2017;31(2):232–55. 10.1521/pedi_2016_30_246.27064853 10.1521/pedi_2016_30_246
39. Noblin JL Venta A Sharp C The validity of the MSI-BPD among inpatient adolescents Assessment 2013 21 2 210 217 10.1177/1073191112473177 23344914
Noblin JL, Venta A, Sharp C. The validity of the MSI-BPD among inpatient adolescents. Assessment. 2013;21(2):210–7. 10.1177/1073191112473177.23344914 10.1177/1073191112473177
40. Normann-Eide E Antonsen BT Kvarstein EH Pedersen G Vaskinn A Wilberg T Are impairments in theory of mind specific to borderline personality disorder? J Pers Disord 2020 34 6 827 841 10.1521/pedi_2019_33_417 30785865
Normann-Eide E, Antonsen BT, Kvarstein EH, Pedersen G, Vaskinn A, Wilberg T. Are impairments in theory of mind specific to borderline personality disorder? J Pers Disord. 2020;34(6):827–41. 10.1521/pedi_2019_33_417.30785865 10.1521/pedi_2019_33_417
41. Onuoha RC Quintana DS Lyvers M Guastella AJ A meta-analysis of theory of mind in alcohol use disorders Alcohol Alcohol 2016 51 4 410 415 10.1093/alcalc/agv137 26755641
Onuoha RC, Quintana DS, Lyvers M, Guastella AJ. A meta-analysis of theory of mind in alcohol use disorders. Alcohol Alcohol. 2016;51(4):410–5. 10.1093/alcalc/agv137.26755641 10.1093/alcalc/agv137
42. Patel AB Sharp C Fonagy P Criterion validity of the MSI-BPD in a community sample of women J Psychopathol Behav Assess 2011 33 3 403 408 10.1007/s10862-011-9238-5
Patel AB, Sharp C, Fonagy P. Criterion validity of the MSI-BPD in a community sample of women. J Psychopathol Behav Assess. 2011;33(3):403–8.10.1007/s10862-011-9238-5
43. Quesque F Rossetti Y What do theory-of-mind tasks actually measure? Theory and practice Perspect Psychol Sci 2020 15 2 384 396 10.1177/1745691619896607 32069168
Quesque F, Rossetti Y. What do theory-of-mind tasks actually measure? Theory and practice. Perspect Psychol Sci. 2020;15(2):384–96. 10.1177/1745691619896607.32069168 10.1177/1745691619896607
44. Richman MJ Unoka Z Mental state decoding impairment in major depression and borderline personality disorder: meta-analysis Br J Psychiatry 2015 207 6 483 489 10.1192/bjp.bp.114.152108 26628692
Richman MJ, Unoka Z. Mental state decoding impairment in major depression and borderline personality disorder: meta-analysis. Br J Psychiatry. 2015;207(6):483–9. 10.1192/bjp.bp.114.152108.26628692 10.1192/bjp.bp.114.152108
45. Ritter K Dziobek I Preißler S Rüter A Vater A Fydrich T Lammers C-H Heekeren HR Roepke S Lack of empathy in patients with narcissistic personality disorder Psychiatry Res 2011 187 1 241 247 10.1016/j.psychres.2010.09.013 21055831
Ritter K, Dziobek I, Preißler S, Rüter A, Vater A, Fydrich T, Lammers C-H, Heekeren HR, Roepke S. Lack of empathy in patients with narcissistic personality disorder. Psychiatry Res. 2011;187(1):241–7. 10.1016/j.psychres.2010.09.013.21055831 10.1016/j.psychres.2010.09.013
46. Rosello B Berenguer C Baixauli I García R Miranda A Theory of mind profiles in children with autism spectrum disorder: adaptive/social skills and pragmatic competence Front Psychol 2020 11 567401 10.3389/fpsyg.2020.567401 33041932
Rosello B, Berenguer C, Baixauli I, García R, Miranda A. Theory of mind profiles in children with autism spectrum disorder: adaptive/social skills and pragmatic competence. Front Psychol. 2020;11:567401. 10.3389/fpsyg.2020.567401.33041932 10.3389/fpsyg.2020.567401
47. Schilling L Moritz S Kriston L Krieger M Nagel M Efficacy of metacognitive training for patients with borderline personality disorder: preliminary results Psychiatry Res 2018 262 459 464 10.1016/j.psychres.2017.09.024 28927866
Schilling L, Moritz S, Kriston L, Krieger M, Nagel M. Efficacy of metacognitive training for patients with borderline personality disorder: preliminary results. Psychiatry Res. 2018;262:459–64. 10.1016/j.psychres.2017.09.024.28927866 10.1016/j.psychres.2017.09.024
48. Semerari A Colle L Pellecchia G Carcione A Conti L Fiore D Moroni F Nicolò G Procacci M Pedone R Personality disorders and mindreading: specific impairments in patients with borderline personality disorder compared to other PDs J Nerv Ment Dis 2015 203 8 626 31 10.1097/NMD.0000000000000339 26153890
Semerari A, Colle L, Pellecchia G, Carcione A, Conti L, Fiore D, Moroni F, Nicolò G, Procacci M, Pedone R. Personality disorders and mindreading: specific impairments in patients with borderline personality disorder compared to other PDs. J Nerv Ment Dis. 2015;203(8):626–31.26153890 10.1097/NMD.0000000000000339
49. Sharp C Vanwoerden S Hypermentalizing in borderline personality disorder: a model and data J Infant Child Adolesc Psychother 2015 14 33 45 10.1080/15289168.2015.1004890
Sharp C, Vanwoerden S. Hypermentalizing in borderline personality disorder: a model and data. J Infant Child Adolesc Psychother. 2015;14:33–45. 10.1080/15289168.2015.1004890.10.1080/15289168.2015.1004890
50. Thirion-Marissiaux A-F Nader-Grosbois N Theory of Mind “emotion”, developmental characteristics and social understanding in children and adolescents with intellectual disabilities Res Dev Disabil 2008 29 5 414 430 10.1016/j.ridd.2007.07.001 17855050
Thirion-Marissiaux A-F, Nader-Grosbois N. Theory of Mind “emotion”, developmental characteristics and social understanding in children and adolescents with intellectual disabilities. Res Dev Disabil. 2008;29(5):414–30. 10.1016/j.ridd.2007.07.001.17855050 10.1016/j.ridd.2007.07.001
51. Vaskinn A Antonsen BT Fretland RA Dziobek I Sundet K Wilberg T Theory of mind in women with borderline personality disorder or schizophrenia: differences in overall ability and error patterns Front Psychol 2015 6 1239 10.3389/fpsyg.2015.01239 26379577
Vaskinn A, Antonsen BT, Fretland RA, Dziobek I, Sundet K, Wilberg T. Theory of mind in women with borderline personality disorder or schizophrenia: differences in overall ability and error patterns. Front Psychol. 2015;6:1239. 10.3389/fpsyg.2015.01239.26379577 10.3389/fpsyg.2015.01239
52. Wells A Cognition about cognition: metacognitive therapy and change in generalized anxiety disorder and social phobia Cogn Behav Pract 2007 14 1 18 25 10.1016/j.cbpra.2006.01.005
Wells A. Cognition about cognition: metacognitive therapy and change in generalized anxiety disorder and social phobia. Cogn Behav Pract. 2007;14(1):18–25. 10.1016/j.cbpra.2006.01.005.10.1016/j.cbpra.2006.01.005
53. Wittchen HU, Zaudig M, Fydrich TS. Strukturiertes Klinisches Interview für DSM-IV. Hogrefe; 1997.
54. Wolkenstein L Schönenberg M Schirm E Hautzinger M I can see what you feel, but I can’t deal with it: impaired theory of mind in depression J Affect Disord 2011 132 1 104 111 10.1016/j.jad.2011.02.010 21420177
Wolkenstein L, Schönenberg M, Schirm E, Hautzinger M. I can see what you feel, but I can’t deal with it: impaired theory of mind in depression. J Affect Disord. 2011;132(1):104–11. 10.1016/j.jad.2011.02.010.21420177 10.1016/j.jad.2011.02.010
55. World-Health-Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines (Vol. 1). World Health Organization; 1992.
56. World-Medical-Association World medical association declaration of helsinki: ethical principles for medical research involving human subjects JAMA 2013 310 20 2191 2194 10.1001/jama.2013.281053 24141714
World-Medical-Association. World medical association declaration of helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191–4. 10.1001/jama.2013.281053.24141714 10.1001/jama.2013.281053
57. Zabihzadeh A Maleki G Hatami A Richman M Alimardani Z Heidari M Affective and cognitive theory of mind in borderline personality disorder: the role of comorbid depression Psychiatry Res 2017 257 144 149 10.1016/j.psychres.2017.07.034 28755605
Zabihzadeh A, Maleki G, Hatami A, Richman M, Alimardani Z, Heidari M. Affective and cognitive theory of mind in borderline personality disorder: the role of comorbid depression. Psychiatry Res. 2017;257:144–9. 10.1016/j.psychres.2017.07.034.28755605 10.1016/j.psychres.2017.07.034
58. Zanarini MC Vujanovic AA Parachini EA Boulanger JL Frankenburg FR Hennen J A screening measure for BPD: the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) J Pers Disord 2003 17 6 568 573 10.1521/pedi.17.6.568.25355 14744082
Zanarini MC, Vujanovic AA, Parachini EA, Boulanger JL, Frankenburg FR, Hennen J. A screening measure for BPD: the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). J Pers Disord. 2003;17(6):568–73. 10.1521/pedi.17.6.568.25355.14744082 10.1521/pedi.17.6.568.25355
