Journal of Personality Disorders, 30(2), 242–260, 2016
© 2016 The Guilford Press
THE INDEPENDENT CONTRIBUTIONS OF
EMOTION DYSREGULATION
AND HYPERMENTALIZATION TO
THE “DOUBLE DISSOCIATION” OF
AFFECTIVE AND COGNITIVE EMPATHY IN
FEMALE ADOLESCENT INPATIENTS WITH BPD
Allison Kalpakci, MA, Salome Vanwoerden, BA, Jon D. Elhai, PhD,
and Carla Sharp, PhD
Harari, Shamay-Tsoory, Ravid, and Levkovitz (2010) demonstrated a “double dissociation” in empathy in borderline personality disorder (BPD), such
that BPD patients had higher affective than cognitive empathy, whereas
controls exhibited the opposite pattern. Two processes that may relate to
this dissociation are emotion dysregulation (ER) and hypermentalization.
However, these interrelated processes have not been studied concomitantly,
and the dissociation of empathy types has not been examined in adolescents
with BPD. This study examined the relations between ER, hypermentalization, and cognitive and affective empathy in 252 adolescent inpatients with
and without BPD. Participants completed a computerized task of hypermentalization and measures of ER and empathy. Findings only partially
replicated Harari et al.’s findings, with differential performance in cognitive
and affective empathy demonstrated across groups. Multivariate analyses
revealed that in both groups, ER related to increased affective empathy.
Hypermentalizing related to decreased cognitive empathy in BPD patients,
whereas hypermentalizing did not relate to either empathy type in non-BPD
patients.
Borderline personality disorder (BPD) is a severe psychiatric disorder marked
by treatment-refractory behavior and poor psychosocial outcomes (American
Psychiatric Association, 2013). Though initially considered a disorder limited
to adults, recent genetic and longitudinal findings have established BPD in
adolescence as a valid diagnostic entity warranting empirical attention (Miller,
Muehlenkamp, & Jacobson, 2008; Sharp & Romero, 2007). Furthermore,
research suggests that adolescents with the disorder experience symptomatology similar to that of their adult counterparts (Sharp & Romero, 2007). For
instance, much like BPD in adults, BPD in adolescents is a highly interpersonal
From University of Houston and Baylor College of Medicine, The Menninger Clinic (A. K., S. V., C. S.);
and University of Toledo (J. D. E.).
Address correspondence to Carla Sharp, PhD, Department of Psychology, University of Houston, 126
Heyne, Houston, TX 77024. E-mail: [email protected]
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disorder (Fonagy & Luyten, 2009; Gunderson, 2007; Linehan, 1993; Sharp,
2014), in that marked impairment in maintaining stable and healthy relationships is one of the most debilitating features of the disorder.
As such, several studies have explored social-cognitive processes that may
relate to the interpersonal dysfunction individuals with BPD experience. One
process is empathy, or the capacity to experience and understand the emotional
and cognitive experiences of others (Eisenberg & Miller, 1987). Empathy can
be conceptualized as a multifaceted construct consisting of cognitive empathy, or the ability to understand another’s perspective and experience (Davis,
1983, 1994; Eisenberg et al., 1994), and affective empathy, or the capacity to
affectively respond in a way similar to what an observed person is feeling or
expected to feel (Davis, 1983, 1994; Eisenberg et al., 1994).
Early clinical accounts (Carter & Rinsley, 1977; Krohn, 1974) refer to
an “empathy paradox” in BPD to describe BPD patients’ apparent heightened
attunement to others’ mental states, despite severe interpersonal dysfunction.
However, empirical evidence for this phenomenon is lacking. This may be
due, in part, to inconsistent definitions and measurement of empathy. Indeed,
several studies purport to examine empathy (see Dinsdale and Crespi, 2013,
for a review) but instead examine empathy-related components or skills (e.g.,
mentalization or theory of mind, emotion recognition and discrimination).
For instance, recent research shows that patients with BPD amplify subjective
perceptions of negative affect in others’ faces (Daros, Uliaszek, & Ruocco,
2014; Mitchell, Dickens, & Picchioni, 2014), suggesting a propensity toward
hyperactive affective empathy in this population. On the other hand, metaanalytic work found BPD-related deficits in recognizing angry, disgusted, and
neutral faces (Daros, Zaskzanis, & Ruocco, 2013).
Studies that have specifically examined empathy in BPD reveal mixed
findings. For example, Guttman and Laporte (2002) used a self-report measure of empathy, the Interpersonal Reactivity Index (IRI; Davis, 1983), and
found that compared with women with anorexia nervosa and healthy controls,
women with BPD had higher mean levels of affective empathy, but lower mean
levels of cognitive empathy. Harari, Shamay-Tsoory, Ravid, and Levkovitz
(2010) elucidated these findings and demonstrated a “double dissociation”
of cognitive and affective empathy in BPD such that, compared to healthy
controls, BPD participants had higher self-reported (using the IRI) levels of
affective empathy than cognitive empathy.
Consistent with Harari et al.’s (2010) findings are studies that have found
that BPD patients exhibit difficulty with perspective taking, but higher levels of
personal distress, or “self-oriented” anxious or tense feelings (Harari, ShamayTsoory, Ravid, & Levkovitz, 2010; New et al., 2012). Providing neurobiological confirmatory support for Harari et al.’s “dissociation” in cognitive and
affective empathy, Dziobek et al. (2011) included fMRI data and found that
BPD patients, compared with controls, had less activation during cognitive
empathy tasks in the Superior temporal Sulcus (STS), an area associated with
inference of others’ mental states (Zaki, Weber, Bolger, & Ochsner, 2009),
but increased activation during affective empathy tasks in the mid insular
cortex (Jackson, Bruent, Meltzoff, & Decety, 2006), an area associated with
personal distress.
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Harari et al.’s findings provide a useful model for understanding problems
of empathy in BPD. However, no studies have expanded upon these findings
and attempted to examine whether certain underlying psychological processes
that are also related to empathy may account for this dissociation. Considering such processes would point to a broader, more comprehensive model of
empathic functioning in this disorder. Two psychological processes central to
borderline pathology, difficulties in emotion regulation (highly uncontrolled
emotional reactivity; Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2006;
Linehan, 1993) and hypermentalization (incorrect, overinference of thoughts
and feelings in self and others; Sharp et al., 2011, 2013), may contribute to
this empathic dysfunction, as discussed here, and should be considered when
studying empathy in BPD.
Emotion dysregulation is defined by Gratz and Roemer (2004) as the
failure to modulate internal emotions, resulting in inappropriate emotional
and behavioral responses. Linehan’s (1993) biosocial theory places problems
with emotion regulation at the forefront of the development and maintenance
of BPD. The empirical literature supports Linehan’s model, as studies using
behavioral-, experimental-, and neurobiological-based methods demonstrate
how difficulties with emotion regulation underlie borderline pathology in both
adults and adolescents (Chapman, Leung, & Lynch, 2008; Donegan et al.,
2003; Ebner-Priemer et al., 2007; Glenn & Klonsky, 2009; Gratz, DixonGordon, Breetz, & Tull, 2013; Gratz & Roemer, 2004; Gratz et al., 2006;
Rathus & Miller, 2002; Sharp et al., 2011).
Research has demonstrated a relation between emotion dysregulation and
empathy. For example, Eisenberg et al. (1994) demonstrated a negative relation between emotion regulation and level of self-reported personal distress in
reaction to an empathy-inducing film. That is, the more emotionally regulated
the participants were, the less likely they were to report feeling sadness and
sympathy in response to empathy-inducing stimuli. In addition, several findings
have demonstrated that empathy is positively correlated with a dispositional
tendency to experience emotions, or emotional sensitivity (Eisenberg et al.,
1999; Eisenberg & Fabes, 1992), intensity and frequency of negative emotions (Davis, 1994), a relation that has been extended to both toddlers and
young children (Robinson, Zahn-Waxler, & Emde, 2001; Rothbart, Ahadi, &
Hershey, 1994). Eisenberg (2005) further stated that while low-to-moderate
levels of sadness are associated with greater levels of empathy, individuals
with high levels of negative emotionality may become overwhelmed by their
own personal distress in empathy-inducing situations.
The other putative process that may affect relationships between empathy
and BPD relates to difficulties in mentalization, or the capacity to accurately
infer others’ mental states. Specifically, Fonagy and colleagues (Fonagy, 1989;
Fonagy & Luyten, 2009; Fonagy, Steele, Steele, Moran, & Higgitt, 1991;
Sharp & Fonagy, 2008) explain how insecure attachment leads to maladaptive mentalizing in which the reflection on self–other relatedness becomes
distorted, thereby disrupting the development of a coherent self. Empirical
evidence supports Fonagy’s theory, with a large body of research pointing
to atypical mentalizing capacity in adults with BPD (Dziobek et al., 2011;
Flury, Ickes, & Schweinle, 2008; Ghiassi, Dimaggio, & Brüne, 2010; Schilling
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et al., 2012; Sharp et al., 2011). More recently, researchers have extended
this research downward by examining mentalizing in adolescents with the
disorder. Recent studies conducted by Sharp et al. (2011, 2013) demonstrated
that adolescent inpatients with BPD exhibited a tendency to “hypermentalize,”
or make overly complex inferences about others’ mental states. That is, they
overinferred others’ mental states by reaching far beyond what the observable
social cues indicate, ultimately leading to misinterpretation of social information. For example (Sharp, 2014; Sharp et al., 2013), person A invites person B
to dinner, but B quickly replies that she is unavailable because of a previously
scheduled engagement. A then assumes that B does not wish to spend time
with her because of a misunderstanding that she recalls from several years
ago, in which A did not attend B’s birthday party. A then generates a complex
narrative about B being “overly sensitive” and “unable to forgive.” This is
referred to as hypermentalizing because although A was using mental states
to explain B’s actions, these mental states were overattributed and heavily
dependent on assumption. Rather, they reflected A’s own mental states at the
time of the original misunderstanding.
The relation between mentalization and empathy is apparent, with
research suggesting that mentalization may approximate cognitive empathy,
or the process of understanding another person’s perspective (Blair, 2008;
De Waal, 2008; Shamay-Tsoory, Aharon-Peretz, & Perry, 2009). Neurobiological research supports these findings, as lesions in the medial frontal
lobes (a brain area implicated for processes related to mentalization) have
been linked with impairment of cognitive empathy (Eslinger, 1998; ShamayTsoory, Tomer, Berger, & Aharon-Peretz, 2003).
Taken together, this research points to a relation between empathy and
core BPD-related processes of hypermentalizing and emotion dysregulation.
However, no studies have endeavored to examine these interrelated processes
concomitantly within the same study, allowing for the discovery of potential
differential and unique relations. In addition, no studies have been conducted
to determine whether the dissociation between cognitive and affective empathy
extends downward to adolescents.
Against this background, the aim of the current study was to address this
gap in the literature by examining how core processes central to borderline
pathology relate to empathy in adolescent inpatients with BPD. Specifically,
the cross-sectional relations between emotion dysregulation, hypermentalization, and cognitive and affective empathy were examined. On the basis of the
previously reviewed literature, we hypothesized that hypermentalizing would
relate to decreased cognitive empathy, and that emotion dysregulation would
relate to increased affective empathy. In addition, we sought to examine the
specificity of these relations for BPD by examining the moderating effects of
BPD status on the relations between emotion dysregulation, hypermentalization, and cognitive and affective empathy. Demonstrating unique relations
among these variables would not only expand upon Harari et al.’s (2010)
findings, but would also provide a preliminary step toward the development
of more comprehensive understanding of empathy in BPD, thus laying the
groundwork for understanding mechanisms of empathic functioning in this
disorder. Because a large body of research points to differential social cognitive
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functioning across gender (Baron-Cohen & Wheelwright, 2004) as well in BPD
prevalence rates (Paris, 2004), only adolescent inpatient females were included.
METHODS
PARTICIPANTS
Adolescent females admitted to an inpatient psychiatric hospital were recruited
for participation in an ongoing research study. Exclusion criteria included
severe aggression, active psychosis, IQ < 70, and/or non-English speaking.
Adolescents who had history of severe violent behavior were screened by
admissions and were not admitted to the hospital because the hospital lacks
infrastructure to accommodate severely aggressive behavior. At the time of
admission, licensed clinicians were consulted to assess whether patients were
stable enough to participate. If there was evidence of cognitive deficits or
psychosis, neuropsychological testing was completed by a licensed staff psychologist to determine whether that adolescent should be excluded from the
study. Of 319 consecutive female admissions to the hospital, 15 were excluded
based on the aforementioned criteria. Of the remaining patients who were
approached for consent, 27 declined participation, one revoked consent, and
15 were excluded based on information obtained after consent was given. In
addition, seven participants were excluded due to missing data on main study
variables. These data were missing at random because adolescents refused to
complete assessments or were discharged from the hospital before assessments
were completed.
A total of 252 adolescent inpatients were given an interview-based measure of BPD, and 107 met criteria for DSM-IV BPD. For the main aim of this
study, all female patients (ages 12–17) meeting criteria for BPD were included
(n = 107; Mage = 15.11, SD = 1.51). In total, 145 (Mage = 15.35, SD = 1.40)
female adolescents did not meet criteria for BPD and constituted the nonBPD psychiatric control group. Psychiatric comorbidity was assessed with
a computerized diagnostic interview at the time of admission, and rates are
presented in Table 1.
MEASURES
Borderline Personality Disorder Diagnosis: Childhood Interview for DSM-IV
Borderline Personality Disorder (CI-BPD). The CI-BPD (Zanarini, 2003) is a
semistructured interview adapted from the borderline module of the Diagnostic
Interview for DSM-IV Personality Disorders (DIPD-IV; Zanarini, Frankenburg,
Sickel, & Yong, 1996) and developed specifically for use with adolescents to
assess BPD. The CI-BPD assesses the nine DSM-IV criteria: symptoms of inappropriate anger, affective instability, chronic feelings of emptiness, identity
disturbance, transient stress-related paranoid ideation or severe dissociative
symptoms, fears of abandonment, recurrent suicidality or self-harm behavior,
impulsivity, and intense interpersonal relationships. Trained interviewers rated
symptoms using 0 for absence of symptom, 1 if the symptom is probably
present, or 2 if the symptom is definitely present. A minimum of five criteria
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TABLE 1. Prevalence Rates of Various Forms of Psychopathology
BPD
n = 107 (42.5%)
Non-BPD
n = 145 (57.5%)
Met full criteria during the past year (%)
Depressive disorder
71
54
Bipolar disorder
10
4
Eating disorder
14
9
Anxiety disorder
72
55
Externalizing disorder
55
28
Note. BPD diagnoses were based on the Childhood Interview for Borderline Personality Disorder
(CI-BPD; Zanarini, 2003). Other psychiatric diagnoses were based on the Computerized Diagnostic
Interview Schedule for Children (Shaffer et al., 2000). These prevalence rates are exclusively with
regard to positive diagnoses in which the adolescent endorsed all necessary diagnostic criteria
(i.e., intermediate diagnoses were not included). Depressive disorder includes major depressive
disorder and dysthymia; bipolar disorder includes mania and hypomania; eating disorder includes
bulimia nervosa and anorexia nervosa; anxiety disorder includes generalized anxiety disorder,
separation anxiety disorder, social phobia, specific phobia, obsessive-compulsive disorder, panic
disorder, agoraphobia, and posttraumatic stress disorder; externalizing disorder includes conduct
disorder, oppositional defiant disorder, and attention deficit hyperactivity disorder.
scored at a 2 is required for a full diagnosis of BPD. A dichotomous score on
the CI-BPD was used in the analyses to determine a diagnosis of BPD. In the
current study, interrater reliability was conducted with 12% of the sample,
with two raters, with kappas ranging from good (κ = 0.77; p < .001) to very
good (κ = 0.89; p < .001) agreement.
Psychiatric Diagnoses: The Computerized Diagnostic Interview Schedule for
Children (C-DISC). The C-DISC (Shaffer et al., 2000) was used to diagnose
psychiatric disorders. This measure covers DSM-IV, DSM-III-R, and ICD10, assessing more than 30 diagnoses. For the purposes of this study, only
current positive diagnoses that met all DSM criteria on the clinical report of
the C-DISC were considered.
Empathy: Basic Empathy Scale (BES). The BES (Jolliffe & Farrington, 2006)
is a 20-item self-report measure with two factors: cognitive empathy (9 items;
e.g., “I find it hard to know when my friends are frightened” [reverse coded])
and affective empathy (11 items; e.g., “I don’t become sad when I see other
people crying” [reverse coded]). Items were rated on a 5-point Likert-type
scale ranging from 1 (Strongly disagree) to 5 (Strongly agree), such that high
scores indicated greater empathy. The sum of the ratings for cognitive empathy
items and affective empathy items yielded cognitive and empathy scale scores,
respectively. The sum of the two subscales yielded a total empathy score.
Internal consistency for the total empathy score in this study was α = 0.85.
Internal consistency was α = 0.75 for the cognitive empathy scale and α = 0.83
for the affective empathy scale.
Hypermentalizing: Movie for the Assessment of Social Cognition (MASC).
The MASC (Dziobek, et al., 2006) is a computerized, performance-based
task for the assessment of mentalizing abilities and is designed to simulate
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real-world social cognitive demands. In this task, participants were asked
to watch a 15-minute film about four characters getting together for a
dinner party. During task administration, the film was stopped at various
points and participants answered questions about the characters’ mental
states (feelings, thoughts, and intentions). For example, one scene in the
film involves a character, Michael, complimenting another character, Sandra,
on her hair, although Sandra appears somewhat reserved in her reaction.
Response options reflect four levels of mentalizing: (a) a hypermentalizing
response (e.g., “She is exasperated about Michael coming on too strong”),
(b) an undermentalizing response (e.g., “She is pleased about his compliment”), (c) a nonmentalizing response (e.g., “Her hair does not look that
nice”), and (d) an accurate mentalizing response (e.g., “She is flattered but
somewhat taken by surprise”). The sum of each response type yielded four
scale scores, reflecting the respective level of mentalizing. In this study, only
the hypermentalizing scale was used. The reliability and validity of the MASC
has been supported in previous studies (Preißler, Dziobek, Ritter, Heekeren,
& Roepke, 2010; Sharp et al., 2011, 2013).
Emotion Dysregulation: Difficulties in Emotion Regulation Scale (DERS).
The DERS (Gratz & Roemer, 2004) is a 36-item self-report measure. Items
are rated on a 5-point Likert scale from 1 (almost never [0–10%]) to 5 (almost always [91–100%]), with higher scores indicating greater difficulties
in emotion regulation. The DERS assesses six aspects of emotion regulation:
nonacceptance of emotion responses, difficulties in engaging in goal-directed
behavior, impulse control difficulties, lack of emotion awareness, limited access
to emotion regulation strategies, and lack of emotional clarity. Each subscale
yields a separate score. In this study, the total score was used. Internal consistency for this study was α = 0.96.
Psychiatric Severity: Child Behavior Checklist (CBCL). The CBCL (Achenbach, 1991) is a 120-item parent-reported broadband measure of psychopathology that has been standardized and normed in children and adolescents
ages 6 to 18. Items are rated on a 3-point scale from 0 (not true), 1 (somewhat
or sometimes true), to 2 (very or often true) for the past 6 months. A total
composite T score was used to control for psychiatric severity in the main
analyses of the current study.
PROCEDURES
Approval for this study was obtained from local institutional review boards.
On admission day, after meeting with research staff, families provided informed
consent and adolescents provided assent to participate in the study. The adolescents had been consecutively admitted to an inpatient unit of a tertiary care
hospital. Adolescent patients completed assessments during the first 2 weeks
of their hospitalization. Trained research coordinators and clinical psychology
graduate students administered self-report assessments and conducted interviews. The principal investigator of the study met monthly with the research
team to review interview-based assessments for reliability and training.
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DATA ANALYTIC STRATEGY
The data analyses involved several steps. First, descriptive analyses on main
study variables, including calculations of means and standard deviations, were
performed. Next, to examine the bivariate relations among main study variables (MASC Hypermentalizing, DERS Emotion Dysregulation, BES Affective
Empathy, and BES Cognitive Empathy), Pearson zero-order correlations were
conducted. Then, to determine whether there were differences in cognitive and
affective empathy in BPD and non-BPD patients, a repeated measures ANOVA
was conducted with empathy type (cognitive/affective) as the within-subjects
factor and group (BPD diagnostic status) was the between-subjects factor. In
order to rule out the possibility that differences in Cognitive and Affective
Empathy scores were due to differential item numbers across the subscales,
item averages for both scales were computed prior to performing study analyses. To ensure that differences in empathy across groups were not due to differential psychiatric severity level, total psychiatric severity, as measured by
the CBCL total psychiatric problems score, was entered as a covariate in the
repeated measures ANOVA.
The bivariate analyses informed the multivariate analyses by identifying
relevant independent variables to be entered in a multivariate regression analysis
with empathy type as the dependent variable(s). To determine whether multivariate relations were specific to borderline personality pathology, the moderating
effect of BPD status (as assessed by the CIBPD) on the relation between hypermentalizing and emotion dysregulation and cognitive and affective empathy
was tested. To statistically evaluate the differences in path coefficients across
the groups, we performed tests of invariance with a chi-square difference test. A
chi-square corresponding to a probability level of less than .05 was the criterion
by which the null hypothesis that the relevant parameters were equal across the
two groups was rejected. The effects of total psychiatric severity (as measured by
the CBCL total psychiatric problems score) on cognitive and affective empathy
were controlled for statistically to ensure that differences in paths across models
were not due to differential psychiatric severity level.
All variables were treated as continuous variables. Maximum likelihood
estimation was used to analyze the data with Amos 4.0 (Arbuckle & Wothke,
1999), which computes full information maximum likelihood estimates in the
presence of missing data. In the BPD group, a total of two participants were
missing data on the DERS, seven participants were missing data on the MASC,
and two participants were missing data on the Affective and Cognitive scales
of the BES. In the non-BPD group, a total of three people were missing data
on the MASC.
RESULTS
PRELIMINARY ANALYSES
In the BPD group, the mean score for emotion dysregulation (DERS Total)
was 122.81 (SD = 23.53) and the mean score for hypermentalizing (MASC
Hypermentalizing) was 8.16 (SD = 4.19). The mean total empathy score was
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3.84 (SD =.53). The means for cognitive empathy (BES Cognitive) and affective
empathy (BES Affective) were 4.01 (SD =.54) and 3.70 (SD = .70), respectively.
The mean for CBCL total psychiatric problems (CBCL) was 71.56 (SD = 3.13).
In the non-BPD group, the mean total score for emotion dysregulation was
99.03 (SD = 29.99) and the mean total score for hypermentalizing was 7.09
(SD = 3.48). The mean total empathy score was 3.75 (SD = .49) and the mean
scores for cognitive empathy and affective empathy were 4.08 (SD = .43) and
3.48 (SD = .65), respectively. The mean for CBCL total psychiatric problems
was 68.62 (SD = 6.40) All data were normally distributed.
BIVARIATE RELATIONS AMONG EMOTION DYSREGULATION,
HYPERMENTALIZING, AND EMPATHY
To examine the bivariate relations among main study variables within the BPD
group, zero-order Pearson’s correlations were conducted. Results revealed that
cognitive empathy was correlated with affective empathy, r = .40, p < .00. Hypermentalizing was negatively correlated with cognitive empathy, r = −.23, p < .02,
but was not significantly correlated with affective empathy, r = −.05, p =.65, or
total empathy, r = −.14, p = .16. Emotion dysregulation was correlated with affective empathy, r = .22, p =.02, but was not significantly correlated with cognitive
empathy, r = .03, p = .75, or total empathy, r = 0.18, p = .07. Hypermentalizing
and emotion dysregulation were not significantly correlated, r = .19, p = .06.
Within the non-BPD group, cognitive empathy was positively correlated
with affective empathy, r = .52, p < .00. Hypermentalizing was not correlated
with cognitive empathy, r = −.06, p =.47, affective empathy, r = .00, p =.98,
or total empathy, r = −.02, p = .79. Emotion dysregulation was correlated
with affective empathy, r = .23, p = .01, but was not correlated with cognitive empathy, r = −.02, p = .79, or total empathy, r = .16, p = .06. Emotion
dysregulation and hypermentalizing were correlated, r = .25, p = .00.
AFFECTIVE AND COGNITIVE EMPATHY IN ADOLESCENT
INPATIENT FEMALES WITH AND WITHOUT BPD
We computed a repeated measures ANOVA, shown in Figure 1, with empathy
type (affective and cognitive) as the within-subjects factor and group (BPD
diagnostic status) as the between-subjects factor. Total psychiatric problems
was included as a covariate. A significant group-by-empathy type interaction
effect was revealed, F(1, 239) = 10.32, p = .00, ηp2 = .04, such that the difference between cognitive and affective empathy was more pronounced in the
non-BPD group. There was also a significant main effect of empathy type, F(1,
239) = 4.62, p = .03, ηp2 =.02, such that across groups, cognitive empathy
was greater than affective empathy. However, there was not a significant main
effect of group, F(1, 239) = 2.18, p =.14, ηp2 = .01.
Partially replicating Harari et al.’s (2010) findings, post-hoc independent
samples t tests revealed that adolescents with BPD had greater affective empathy (M = 3.70, SD = .70) than non-BPD (M = 3.48, SD = .65) adolescents, t(1,
248) = −2.66, p = .01. However, there was no difference between the groups
in cognitive empathy, t(1, 248) = 1.12, p = .27.
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FIGURE 1. Repeated measures ANOVA with empathy type (affective/empathy) as
the within-subjects factor and group as the between-subjects factor. Total psychiatric
problems (as measured by the Child Behavior Checklist [CBCL; Achenbach, 1991])
was included as a covariate in the repeated measures ANOVA.
THE MODERATING EFFECT OF BPD DIAGNOSTIC STATUS
ON THE UNIQUE MULTIVARIATE RELATIONS BETWEEN
HYPERMENTALIZING AND EMOTION DYSREGULATION
AND COGNITIVE AND AFFECTIVE EMPATHY
To evaluate whether hypermentalizing and emotion dysregulation related
to cognitive and affective empathy in adolescent inpatient females with and
without BPD, hypermentalizing and emotion dysregulation and CBCL total
psychiatric problems were entered as independent variables and cognitive and
affective empathy were entered as dependent variables into a multigroup multivariate regression model using Amos 21.0. A test of the moderating effect of
BPD status (as assessed by the CIBPD) was performed on the relation between
hypermentalizing and emotion dysregulation, controlling for psychiatric severity, and cognitive and affective empathy. All indicators were treated as manifest,
and to determine the regression model, the individual pathway coefficients
for the residual error variances were set at 1, whereas the significance level
of the individual pathways was set at alpha < .05. The covariance between
hypermentalizing and emotion dysregulation was constrained to 0. Given the
moderate correlation between cognitive and affective empathy (shown in the
bivariate analyses), the error residuals of cognitive and affective empathy were
unconstrained. Similarly, all other parameters were freely estimated.
As shown in Figure 2, results demonstrated that among adolescent
females with BPD, emotion dysregulation was related to affective empathy
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FIGURE 2. Multigroup multivariate regression model exploring the unique relations
of emotion dysregulation and hypermentalizing with affective and cognitive empathy
in adolescent inpatient females. The bolded values represent standardized regression
coefficients for BPD patients. The nonbolded values following the / represent
standardized regression coefficients for non-BPD patients. Errors of affective and
cognitive empathy are correlated. The correlations between emotion dysregulation
and hypermentalizing were constrained to 0. BPD diagnosis was based on the
Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD; Zanarini,
2003); Emotion Dysregulation = Total scale from the Difficulties in Emotion
Regulation Scale; Hypermentalizing = Hypermentalizing scale from the Movie
for the Assessment of Social Cognition; Affective Empathy = Affective Empathy
scale from the Basic Empathy Scale; Cognitive Empathy = Cognitive Empathy
scale from the Basic Empathy Scale. The effects of total psychiatric problems
(Child Behavior Checklist [CBCL; Achenbach, 1991]) on Cognitive and Affective
Empathy were controlled for statistically. **p < .01. ***p < .001.
(β = .01, SE= .00, p = .01), but was not related to cognitive empathy (β = .00,
SE = .00, p = .43). Hypermentalizing related to cognitive empathy (β = −.03,
SE = .01, p = .01), but did not relate to affective empathy (β = −.02, SE = .02,
p = .28). CBCL total psychiatric problems was not related to affective empathy
(β = −.01, SE = .01, p = .53) or cognitive empathy (β = .01, SE = .01, p = .60).
Among adolescent females without BPD, emotion dysregulation related
to affective empathy (β = .01, SE = .00, p = .003), but did not relate to cognitive empathy (β = .00, SE = .00, p = .87); however, hypermentalizing was not
related to either affective empathy (β = −.01, SE = .02, p = .43) or cognitive
empathy (β = .00, SE = .01, p = .74). Finally, CBCL total psychiatric problems
was related to cognitive empathy (β = −.01, SE = .01, p = .02) but not affective
empathy (β = .01, SE = .01, p = .39).
To evaluate the differences in path coefficients statistically, we conducted
chi-square difference tests between the BPD and non-BPD groups. For the
main study pathways, we compared the full model with the restricted model,
including the equality constraints for four paths: (a) emotion dysregulation
to affective empathy, (b) emotion dysregulation to cognitive empathy, (c)
hypermentalizing to affective empathy, and (d) hypermentalizing to cognitive
empathy. According to the results, the null hypothesis that coefficients were
equal across the two groups was not rejected in all four cases: (a) χ2 = .34,
p = .56; (b) χ2 = .61, p = .33; (c) χ2 = .05, p = .83; and (d) χ2 = 2.90, p = .09.
Hence, there was no statistically significant difference between the groups on
any of the main study pathways.
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253
We also compared the full model with the restricted model, including
the equality constraints for two paths: (a) total psychiatric problems to cognitive empathy and (b) total psychiatric problems to affective empathy. Results
revealed a statistically significant difference between the groups on the pathway
from total psychiatric problems to cognitive empathy (χ2 = 3.38, p = .05) but
not affective empathy (χ2 = 1.08, p = .29).
DISCUSSION
The aim of the current study was to examine how core processes central to
borderline pathology, emotion dysregulation, and hypermentalization relate to
empathy in female adolescent inpatients with BPD. This study therefore takes a
preliminary step toward a broader goal of characterizing empathic functioning
in BPD. Partially replicating Harari et al.’s (2010) findings, results revealed that
female adolescents with BPD exhibited significantly higher affective empathy
than non-BPD inpatient female adolescents. There were, however, no differences in cognitive empathy between the two groups. Furthermore, although
there was a dissociation in cognitive and affective empathy in BPD, cognitive
empathy was greater than affective empathy in both BPD and non-BPD groups.
Multigroup moderation analyses revealed that in adolescents both with and
without BPD, emotion dysregulation was associated with increased affective
empathy. However, in the BPD group, hypermentalizing was associated with
decreased cognitive empathy, whereas in the non-BPD group, hypermentalizing was not related to either empathy type.
The current study’s finding that cognitive empathy was significantly
higher than affective empathy in BPD supports Harari et al.’s (2010) contention that there is a dissociation of cognitive and affective empathy in this
disorder. However, the fact that cognitive empathy was higher than affective
empathy stands in contrast to Harari et al.’s findings of higher affective than
cognitive empathy in adults with the disorder. Furthermore, in this study the
dissociation of empathy types was demonstrated in both BPD and non-BPD
groups, with an even greater dissociation in non-BPD than in BPD adolescents.
Therefore, it is possible that the dissociation of empathy types is a feature
of empathic processing in adolescents with psychiatric disorders in general,
rather than those with BPD specifically. This possibility is bolstered by findings of discrepancies across affective and cognitive empathy in other psychiatric disorders (Dziobek et al., 2011; Maurage et al., 2011; Shamay-Tsoory
et al., 2007) and evidence of the existence of two neurobiological systems for
empathy: a basic emotional contagion system, and a more advanced cognitive
perspective-taking system (Shamay-Tsoory et al., 2009).
Partially replicating Harari et al.’s (2010) findings, affective empathy
was higher in BPD than in non-BPD psychiatric inpatients. However, there
was no difference in cognitive empathy levels between the two groups. This
deviation may arise from use of different empathy measures (the BES in the
current study, and the IRI [Davis, 1983] in Harari et al., 2010). These measures
operationalize cognitive empathy differently, with scales reflecting related, but
not identical, concepts. For example, the BES cognitive empathy scale includes
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statements like “When someone is feeling ‘down’ I can usually understand how
they feel” and “I can often understand how people are feeling even before they
tell me.” Inherent in these items is a sense of certainty regarding knowing what
others are experiencing. Instead of true cognitive empathy, which would be
the capacity to understand what others are feeling and thinking, the cognitive
empathy scale of the BES may instead reflect the level of conviction regarding
knowing how others are feeling or thinking. This pattern of increased certainty
about others’ thoughts was demonstrated in an emotion recognition task conducted by Schilling et al. (2012), with findings that although BPD participants
performed similarly to healthy controls, they nonetheless rated themselves as
more confident and certain than did healthy controls.
On the other hand, the IRI cognitive empathy scale (used in Harari et al.,
2010) consists of the Perspective Taking and Fantasy scales, with the former
appearing to approximate level of curiosity and reflection of others’ mental
states (e.g., “When I’m upset at someone, I usually try to ‘put myself in his
shoes’ for a while,”) and the latter reflecting an ability to cognitively insert
oneself into abstract scenarios (e.g., “When I watch a good movie, I can very
easily put myself in the place of a leading character”). Both aforementioned
abilities have been found to be impaired in individuals with BPD (Fonagy,
1991; Ha, Sharp, Ensink, Fonagy, & Cirino, 2013; Katznelson, 2014; Sharp
et al., 2011), and hence the IRI scale may be more sensitive to BPD-related
cognitive empathy deficits than the BES scale.
At the bivariate level, significant correlations between hypermentalizing
and cognitive empathy in the BPD group, but nonsignificant findings between
cognitive empathy and hypermentalizing in the non-BPD group, preliminarily
suggest differential group-specific relations among these processes. Multivariate analyses support this interpretation, as path analyses revealed that emotion
dysregulation related to increased affective empathy but was not related to
cognitive empathy, and that hypermentalizing related to decreased cognitive
empathy but was not related to affective empathy. A test of the moderating
effect of BPD status was included to determine the specificity of these relations
to BPD pathology. Although there were no statistically significant differences
in the path estimates between samples, the path from hypermentalizing to
cognitive empathy was significant only in the BPD group.
The fact that the hypermentalizing to cognitive empathy path was significant only in the BPD group may indicate increased relevance of this process
in empathy to BPD; however, given the nonsignificant moderation, this interpretation is tempered significantly. Instead, these findings may suggest that
this process is important to empathy in adolescent psychiatric populations
in general, with potentially enhanced importance to BPD. Therefore, these
effects may be transdiagnostic rather than BPD-specific. This nonsignificant
finding also may have arisen from the use of the DSM-IV BPD cutoff score.
Rather than performing a multigroup moderation, it may have been useful to
examine the moderating effect of a continuous BPD features score. This would
not only have increased power, but also would have allowed for the investigation of these pathways across the full range of BPD pathology. However,
we chose to use BPD diagnosis as a categorical moderator due to the severity of the sample. Given the study’s aims of investigating the mechanisms of
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255
dysfunctional empathic processing in BPD, considering the full presentation
of the disorder was central to the design of the study.
Although conclusions regarding causality cannot be generated due to
the cross-sectional design of the study, findings tentatively provide evidence
for unique and differential relations among these processes. That is, emotion dysregulation may relate specifically to overactive affective empathy, and
hypermentalizing may relate specifically to impaired accuracy of cognitive
empathy in BPD.
Two interpretations, the first one offered by Harari et al. (2010), may
help contextualize the present study’s findings. Because affective empathy
is akin to vicariously experiencing others’ emotions (Gallese & Goldman,
1999), and because individuals with BPD have shown heightened sensitivity
to others’ emotional expressions in some previous studies (Lynch et al., 2006;
Wagner & Linehan 1999), affective empathy may be more readily activated in
those with the disorder. This interpretation falls in line with previous findings
of a negative relation between regulated emotions and empathy (Eisenberg,
2000) and may suggest that high affective empathy in BPD is a by-product
of chronic dysregulated mood. Eisenberg et al.’s (1988) distinction between
sympathy and personal distress may help further contextualize these findings.
According to Eisenberg, whereas sympathy is an other-oriented response that
arises out of general interest and concern for another, personal distress is a selffocused response to emotion induction. In the case of adolescents with BPD,
high affective empathy may reflect the latter. The current study’s finding of a
unique link between emotion dysregulation and supports this interpretation.
A second interpretation, by Fonagy and Luyten (2009), is that the dissociation of affective and cognitive empathy may be explained by a lack of
integration between higher- and lower-order social-cognitive systems, such
that transitions between the two systems are not flexible, especially under
conditions of high emotional arousal or stress, leading to incorrect mentalizing. This is also consistent with Sharp’s (2014) hypermentalizing approach
to BPD, which suggests that failure to integrate higher- and lower-order socialcognitive systems results in hypermentalizing.
Although both of these interpretations are plausible, they are merely
hypotheses because they remain untested by the current study. Furthermore,
empathic functioning in BPD is likely more complex than what is offered by
these interpretations, as a fully comprehensive model of BPD would likely
incorporate both explanations. As such, future studies should aim toward
the development of comprehensive understanding of empathic functioning
in BPD, using the present study’s findings of differential relations among
these constructs to guide model development. Specifically, future research that
can tease apart these processes through context-specific tasks may augment
these findings. For example, the impact of emotion dysregulation on affective
empathy may be especially pronounced in situations of high stress or of high
personal relevance to the individual. It is also possible that the capacity to
affectively empathize with others may differentially depend on the valence
of others’ emotions. That is, individuals with BPD may have the capacity to
experience emotional contagion in response to others’ negative emotions, but
they may not experience the same levels of affective empathy for nonnegative
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emotions. Findings from a recent meta-analysis that adults with BPD display
a tendency to attribute negative emotions to neutral faces (Mitchell et al.,
2014) suggest that this may be a possibility.
The findings of the present study are limited by several factors. Most
importantly, the cross-sectional design of this study, as previously discussed,
limits the interpretation of these findings by excluding causal explanations.
Although this study makes a valuable first step toward understanding the
interrelations among emotion dysregulation, hypermentalizing, and cognitive and affective empathy, a broad theory of empathic functioning in BPD
cannot be tested with this study design. Furthermore, the relations among
the variables are likely more complex than the statistical analyses tested. For
example, bidirectional relations likely exist among hypermentalizing, emotion
regulation, and cognitive and affective empathy. Future research should make
use of structural equation modeling to test these relations.
Second, the conceptual definition of empathy has not been agreed upon
in the empirical literature. Although our study takes a broad view of empathy by operationalizing both affective emotional contagion and perspective
taking as empathy, we acknowledge that precisely what defines empathy is
still a matter of debate in the field. Many would argue in favor of a narrow
conceptualization of empathy, including only affective response to others’
emotional states as true empathy, and regarding cognitive empathy as mentalizing, a distinct process altogether (De Vignemont & Singer, 2006). However,
given the findings of the present study, this definition may be problematic, as
findings suggest that it is difficult to disentangle affective empathy from the
effects of dysregulated mood.
Along this line, we acknowledge that including a measure of mentalizing as a predictor of cognitive empathy may appear redundant to some who
consider these constructs as synonymous (Shamay-Tsoory et al., 2009). Others, however, consider mentalization as a unique and complex process that
represents a culmination of multiple affective and cognitive systems operating synergistically (Sharp, 2014). The aim of our study was not to settle the
debate regarding how to define these constructs. However, parsing out these
complex interrelations is crucial if future models of empathic functioning in
BPD are to be developed.
Another notable limitation is that measures of empathy and emotional
dysregulation were both self-report questionnaires and were therefore subject to shared method variance and the effects of social desirability bias.
Future research could improve upon this limitation by using experimentaland neurobiological-based measures of emotion dysregulation (Bornovalova,
Hicks, Iacono, & McGue, 2009; Gratz et al., 2006) and empathy (Dziobek
et al., 2011; Hagenhoff et al., 2013; New et al., 2012). In addition, the use of
a female-only, not severely aggressive, sample of inpatient adolescents limits
the generalizability of the study findings.
Notwithstanding these limitations, the present study has several important strengths. First, the use of an interview-based measure of BPD bolsters
the validity of the BPD diagnosis. Second, the use of an in vivo mentalizationbased task is particularly valuable because it better approximates the everyday demands of social interactions than do traditional self-report measures.
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Third, our findings add to a growing body of literature which has identified
that adolescents with BPD hypermentalize, strengthening the assertion that
adolescents with BPD utilize alternative, unusual forms of mentalizing to
understand others’ mental states rather than exhibiting a deficit or failure to
mentalize (Sharp et al., 2011, 2013). Most importantly, this study is the first
to consider core BPD-related constructs of emotion dysregulation and hypermentalizing in the investigation of empathy in BPD. It is also the first study
to consider cognitive and affective empathy separately in adolescents with
BPD. By including these constructs in the same analyses and demonstrating
differential relations among the variables, we suggest that in order to improve
empathic functioning in adolescents with this disorder, both mood-related and
social-cognitive processes must be considered and therapeutically targeted.
Taking into consideration the preliminary nature of the findings, this study
lays the groundwork for future work in this area and a more comprehensive
understanding of social-cognitive functioning in adolescents with this severe
disorder.
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