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

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Abstract

Empirical evidence and therapeutic interactions have suggested that individuals with borderline personality disorder (BPD) may demonstrate enhancements in aspects of social-emotional cognition. To assess the empirical evidence for this phenomenon, and to comprehensively evaluate alternative hypotheses for its possible role in BPD etiology and symptoms, the authors systematically searched the literature for investigations of empathy in BPD and reviewed 28 studies assessing a range of empathic abilities. Considered together, these data demonstrated comparable levels of evidence for enhanced, preserved, and reduced empathic skills in individuals with BPD. Evidence for empathic enhancements is thus substantial but inconsistent across studies, being found mainly under more socially interactive experimental paradigms. Based on the results of the review and previous explanations for BPD symptoms, the authors propose a new model for explaining the borderline paradox: that a combination of increased attention to social stimuli and dysfunctional social information processing may account in part for the specific empathic enhancements and reduced overall social functioning in BPD.
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Journal of Personality Disorders, 26, 2012, 071
© 2012 The Guilford Press
THE BORDERLINE EMPATHY PARADOX:
EVIDENCE AND CONCEPTUAL MODELS FOR
EMPATHIC ENHANCEMENTS IN BORDERLINE
PERSONALITY DISORDER
Natalie Dinsdale, BS, and Bernard J. Crespi, PhD, FRSC
Empirical evidence and therapeutic interactions have suggested that
individuals with borderline personality disorder (BPD) may demon-
strate enhancements in aspects of social-emotional cognition. To as-
sess the empirical evidence for this phenomenon, and to comprehen-
sively evaluate alternative hypotheses for its possible role in BPD
etiology and symptoms, the authors systematically searched the litera-
ture for investigations of empathy in BPD and reviewed 28 studies as-
sessing a range of empathic abilities. Considered together, these data
demonstrated comparable levels of evidence for enhanced, preserved,
and reduced empathic skills in individuals with BPD. Evidence for em-
pathic enhancements is thus substantial but inconsistent across stud-
ies, being found mainly under more socially interactive experimental
paradigms. Based on the results of the review and previous explana-
tions for BPD symptoms, the authors propose a new model for explain-
ing the borderline paradox: that a combination of increased attention to
social stimuli and dysfunctional social information processing may ac-
count in part for the specific empathic enhancements and reduced
overall social functioning in BPD.
Clinical anecdotes and recent empirical evidence have suggested that in-
dividuals with borderline personality disorder (BPD) may demonstrate en-
hanced empathy in spite of impaired interpersonal functioning, a paradox
referred to as “borderline empathy” (Franzen et al., 2011; Krohn, 1974).
Drawing from therapeutic interactions with borderline patients, the psy-
choanalyst Alan Krohn (1974) first identified the paradoxical nature of the
diagnosis, describing how some individuals with BPD appear to possess
an uncanny sensitivity to other people’s subconscious mental content and
This article was accepted under the editorship of Paul S. Links.
From Simon Fraser University.
Address correspondence to Bernard J. Crespi, Professor of Evolutionary Biology, Simon Fra-
ser University, Burnaby, BC V5A 1S6, Canada; E-mail: crespi@sfu.ca
We are grateful to Felix Breden, Alex Chapman, three anonymous reviewers, and members of
the Simon Fraser University Fab-Lab and the University of California-Santa Barbara Center
for Evolutionary Psychology for helpful comments and discussion, and we thank NSERC for
financial support.
2 DINSDALE AND CRESPI
states, despite their inability to coherently integrate such information into
stable concepts of self and other that are fundamental to healthy interper-
sonal functioning. Both Krohn (1974) and Carter and Rinsley (1977) pro-
posed that enhanced empathic sensitivity develops in the borderline child
in response to confusing or neglectful parenting, which motivates the child
toward increased empathic functioning.
Aside from the models based on Krohn (1974), there have been few at-
tempts to explain the causes underlying borderline empathy or its role in
BPD etiology and symptoms. This general lack of study may be attribut-
able in part to the questions of whether or not the phenomenon actually
exists, and furthermore, if it can be clearly and reliably documented and
explained. Recent studies have reported both enhanced (i.e., Fertuck et
al., 2009; Franzen et al., 2011; Frick et al. 2012) and impaired (i.e., Prei-
ßler, Dziobek, Ritter, Heekeren, & Roepke, 2010) social cognition in BPD,
but the evidence for borderline empathy has yet to be comprehensively
reviewed and evaluated in the context of alternative hypotheses for causa-
tion. In this article, we evaluate the existing evidence for enhanced empa-
thy in BPD by systematically searching the literature and providing an
overview of the relevant studies with consideration of their varying meth-
odological approaches. We synthesize these findings in the context of cur-
rent theories that address the roles of empathy in psychiatric illness, de-
velop a new, testable hypothesis based on increased attention to social
stimuli, and suggest directions for future research in BPD based on our
findings and model.
METHODS
Literature was reviewed using the online databases Web of Science and
PubMed. For the purposes of this article, the term empathy refers to a
range of skills that include both emotional and cognitive components (Gal-
lup, 1979; Rankin, Kramer, & Miller, 2005; Singer, 2006; Smith, 2006). It
is important to distinguish this definition of empathy and empathic skills
from conceptualizations of empathy as positive social-emotional mental
connections that foster cooperation, altruism, and well-being of the re-
cipient (e.g., Baron-Cohen, 2011). Given the numerous definitions for de-
scribing empathizing and mentalizing in the literature, several search
terms were used to ensure that all studies examining any domain of em-
pathic skill were included. The following terms were chosen a priori and
were searched in conjunction with “borderline personality disorder”: em-
pathy; theory of mind; mentalizing; borderline empathy; and emotion rec-
ognition. All references and cited articles from the selected studies were
reviewed to check for additional relevant articles. For inclusion, articles
needed to empirically assess an interpersonal empathic skill (e.g., facial
emotion recognition, mental state attribution, using the definition of em-
pathy described above) or self-reported empathy in a borderline popula-
tion compared to appropriate controls, or as a function of borderline fea-
THE BORDERLINE EMPATHY PARADOX 3
tures in a nonclinical sample. Because affective instability is a diagnostic
criterion for BPD (American Psychiatric Association [APA], 2000), articles
that assessed only affective regulation skills were excluded. Only peer-
reviewed empirical studies were included; reviews, supplementary materi-
als, and meeting abstracts were not.
RESULTS
The literature search yielded 131 articles, of which 28 met the criteria for
inclusion. These articles assessed various aspects of empathy and were
organized into categories based on the ability under study and the meth-
odological approach. The six categories included: (1) nonverbal sensitivity;
(2) emotion recognition; (3) self-reported empathic skills; (4) emotional in-
telligence; (5) inferring mental states from passive stimuli such as photo-
graphs, movies, cartoons, and stories; and (6) mentalizing in interactions
with active stimuli. One study (Harari, Shamay-Tsoory, Ravid, & Levkov-
itz, 2010) investigated both self-reported empathic skills and mental state
attribution from stimuli and was therefore included in both categories.
Table 1 summarizes the articles in each empathic category and the
number of findings reporting enhanced, reduced, or comparable perfor-
mance of borderline individuals relative to controls. Overall, the 28 stud-
ies employed 19 different empathic tests and reported 41 relevant find-
ings: 14 reported enhanced skills, 13 reported reduced skills, and 14
reported similar skills. Evaluating the patterns and causes of variation
among studies of empathy in BPD requires consideration of the proce-
dures deployed and their findings in each category.
NONVERBAL SENSITIVITY
In the first study to explicitly investigate the borderline empathy phenom-
enon, Frank and Hoffman (1986) used the Profile of Nonverbal Sensitivity
(PONS; Depaulo & Rosenthal, 1979) in a sample of 10 female borderline
patients and 14 sex- and education-matched neurotic control subjects
and reported that individuals with BPD demonstrated a heightened sensi-
tivity to nonverbal cues relative to the clinical controls in the study.
EMOTION RECOGNITION
Emotion recognition has received the most empirical attention of all em-
pathic skills in borderline populations. Based on a review of six studies,
Domes, Schulze, and Herpertz (2009) concluded that individuals diag-
nosed with BPD demonstrate subtle impairments in basic emotion recog-
nition, a heightened sensitivity to detecting negative emotions, and a neg-
ativity bias when appraising ambiguous stimuli. Five of these six studies
used similar facial stimuli (Pictures of Facial Affect; Ekman, 1993; Ekman
& Friesen, 1976, 1979), so although the results may be reliable, they may
4
TABLE 1. Studies Reporting Enhanced, Reduced, or Comparable Empathic Skills in BPD
Empathic
Domain NStudy Task
Sex Difference
on Task in
Nonclinical
Populations Subjects
BPD Performance Relative to Controls
Enhanced Reduced Comparable
Nonverbal
sensitivity
1 Frank & Hoff-
man, 1986
Profile of
Nonverbal
Sensitivity
Female advan-
tage (1)
10 BPD patients & 14 non-
BPD clinical controls
(100% female)
p < .02
Emotion
recogni-
tion
11 Levine et al.,
1997
Pictures of
Facial Affect
(PFA)
Female advan-
tage (1)
30 BPD patients (67% fe-
male) & 30 nonclinical
controls (50% females)
p < .001
Wagner & Line-
han, 1999
Japanese and
Caucasian
Facial Ex-
press. of
Emotion
Female advan-
tage (1)
21 BPD subjects with his-
tory of sexual abuse &
41 non-BPD subjects
with and without history
of abuse (100% female)
p < .05 (fear) p < .05 (neutral) p = ns (happy)
Bland et al.,
2004
PFA Female advan-
tage (1)
35 BPD patients & 35 non-
clinical controls (100%
female)
p = .007
Lynch et al.,
2006
PFA Female advan-
tage (1)
20 BPD patients (85% fe-
male) & 20 nonclinical
controls (85% female)
p < .05
Minzenberg et
al., 2006
PFA, BLERTaFemale advan-
tage (1)
43 BPD patients (88% fe-
male) & 26 nonclinical
controls (89% female)
p = .02
Domes et al.,
2008
PFA Female advan-
tage (1)
25 BPD patients & 25 non-
clinical controls (100%
female)
p = .925
Dyck et al.,
2009
FAN testb, ER
Testc
Female advan-
tage (1)
19 BPD patients (89% fe-
male) & 19 nonclinical
controls (89% female)
p = .50, p = .58
Guitart-Masip
et al., 2009
PFA Female advan-
tage (1)
10 BPD patients (50% fe-
male) & 10 nonclinical
controls (50% female)
p = .01 (disgust) p = ns (happy &
angry)
Merkl et al.,
2010
PFA Female advan-
tage (1)
11 BPD patients and 9
nonclinical controls
(100% female)
p = .04 (fear) p = ns (other emo-
tions)
5
Gardner et al.,
2010
PDQ-4-BPDd,
ATQe, PFA
Female advan-
tage (1)
150 nonclinical adults
(70% females)
High ATQ & high
BPD positively
predict anger
recognition, p <
.001
Low ATQ & high
BPD negatively
predict anger
recognition, p <
.001
Unoka et al.,
2011
Ekman 60
Faces Test
Female advan-
tage (1)
33 BPD patients (88% fe-
male) & 32 nonclinical
controls (94% female)
p < .0001
Self-
reported
empathy
2 Guttman & La-
porte, 2000
Interpersonal
Reactivity
Index
Female advan-
tage (2, 3)
27 BPD patients & 28 clin-
ical controls & 27 non-
clinical controls (100%
female)
p < .01 (affective
empathy)
p < .01 (cognitive
empathy)
Harari et al.,
2010
Interpersonal
Reactivity
Index
Female advan-
tage (2, 3)
20 BPD patients (90% fe-
male) & 22 nonclinical
controls (86% female)
p = .038 (cognitive
empathy)
p = .205 (affective
empathy)
Emotional
intelli-
gence
4 Park et al.,
1992
Derived
scale from
Gardner’s
personal
intelligence
concept
Unknown; task
designed
specific-
ally for this
study
23 BPD patients (78% fe-
male) & 38 outpatients
with other PD diagnoses
(61% female)
p < .01
Hertel et al.,
2009
Mayer-Salo-
vey-Caruso
Emotional
Intelligence
Test (MS-
CEIT)
Female advan-
tage (4)
19 BPD patients (100% fe-
male) & 66 patients with
other mental disorders
(45% female) & 94 non-
clinical controls (67%
female)
p < .01
Gardner &
Qualter, 2009
Multiple BPD
measures,
MSCEIT,
Schutte
Emotional
Intelligence
Scale (SEIS)
Female advan-
tage (4, 5)
523 nonclinical adults
(78% female)
Overall BPD score
negatively pre-
dicted overall
trait and ability
EI, p < .001
Ability to perceive
emotions not
related to BPD
score, p = ns
Beblo et al.,
2010
MSCEIT, Test
of Emotional
Intelligence
(TEMINT)
Female advan-
tage (4, 6)
19 BPD patients (84% fe-
male) & 20 nonclinical
controls (85% female)
p = .264, p = .10
continued
6
Empathic
Domain NStudy Task
Sex Difference
on Task in
Nonclinical
Populations Subjects
BPD Performance Relative to Controls
Enhanced Reduced Comparable
Mentaliz-
ing skills
using
passive
stimuli
7 Arntz et al.,
2009
Advanced
Theory of
Mind Test
Mixed (7, 8) 16 BPD patients & 16
cluster-C PD subjects
and 28 nonclinical con-
trols (100% female)
p < .07
Fertuck et al.,
2009
Reading the
Mind in the
Eyes Test
(RMET)
Female advan-
tage (9)
30 BPD patients (87% fe-
male) & 25 nonclinical
controls (60% females)
p < .001
Frick et al.,
2012
Reading the
Mind in the
Eyes Test
(RMET)
Female advan-
tage (9)
21 BPD patients (100%
female) & 20 nonclinical
controls (100% female)
p < 0.01
Ghiassi et al.,
2010
Mental State
Attribu-
tion Task-
Sequencing
and Ques-
tionnaire
Unknown for
this particu-
lar task
50 BPD patients (92% fe-
male) & 20 nonclinical
controls (85% females)
p = ns
Harari et al.,
2010
Faux-Pas Task Female advan-
tage (10)
20 BPD patients (90%
female) and nonclinical
controls
Cognitive under-
standing,
p = .027
Affective under-
standing, p =
.423
Preißler et al.,
2010
Movie for As-
sessment
of Social
Cognition
(MASC),
RMET
Females =
males (11),
Female ad-
vantage (9)
64 BPD patients & 38 non-
clinical subjects (100%
female)
p = .001 p = .58
TABLE 1. Continued
7
Scott et al.,
2011
MSI-BPDf,
RMET
Female advan-
tage (9)
46 undergraduate stu-
dents (76% females)
High BPD group
more accurate
for negative
emotions, p <
.05
No group differ-
ences for posi-
tive and neutral
emotions,
p = ns
Mentaliz-
ing skills
using
inter-
active
stimuli
3 Ladisich & Feil,
1988
Gieben Test
(GT), Un-
pleasant
Person Hier-
archy Test
(UPHT)
Unknown,
Task de-
signed spe-
cifically for
this study
20 BPD patients & 39 non-
BPD psychiatric patients
(sex composition not
reported)
p < .05
Flury et al.,
2008
Infer states of
partner in
dyadic inter-
actions
Unknown 76 undergraduate stu-
dents (61% female)
High BPD group
more accureate-
ly, p < .01
Franzen et al.,
2011
Simulated
interaction
game with
monetary
exchange
Unknown 30 BPD patients (73% fe-
male) & 30 non-clinical
controls (73% female)
p < .003
Notes: aBell-Lysaker Emotion Recognition Test; bFear-Anger-Neutral Test; cEmotion Recognition Test; dPersonality Diagnostic Questionnaire-fourth ed.-
BPD Scale; eAdult Temperament Questionnaire-Short Form; fMcLean Screening Instrument for BPD.
References: (1) Geary, 2010; (2) Mestre et al., 2009; (3) Berthoz et al., 2008; (4) Day & Carroll, 2004; (5) Schutte et al., 1998; (6) Amelang & Steinmayr,
2006; (7) Bosacki, 2000; (8) Russell et al., 2007; (9) Baron-Cohen et al., 2001; (10) Baron-Cohen et al., 1999; (11) Smeets et al., 2009.
8 DINSDALE AND CRESPI
not be generalizable to studies that employ tasks and stimuli more closely
resembling realistic social interactions.
Dyck et al. (2009) assessed facial emotion recognition abilities in 19 bor-
derline personality patients (17 females) with and without comorbid post-
traumatic stress disorder and in sex-matched healthy controls using two
different tasks with colored facial stimuli (from Gur et al., 2002). The Fear
Anger Neutral (FAN) test asks subjects to rapidly discriminate between
negative and neutral facial expressions, and the Emotion Recognition (ER)
test involves the precise identification of an emotion out of five possibili-
ties (sadness, happiness, anger, fear, and neutral) with no time limits.
When time was constrained, borderline subjects performed more poorly
than did the control group, misinterpreting neutral faces as negative sig-
nificantly more often. In the absence of time limits, the borderline subjects
performed as well as the controls, suggesting that individuals with BPD
may process complexly integrated emotional stimuli more slowly than
healthy controls; a similar conclusion was supported by Minzenberg,
Poole, and Vinogradov (2006; reviewed in Domes et al., 2009).
Guitart-Masip et al. (2009) compared the emotion discrimination abili-
ties of 10 patients with BPD (5 females) and 10 nonclinical sex-matched
controls by presenting pairs of neutral and emotional faces (happiness,
fear, disgust, anger) from the Ekman and Friesen (1979) series. Stimuli
were presented for 700 ms and subjects were instructed to press a button
corresponding to the emotional face. Patients demonstrated a reduced
performance relative to controls when identifying fear and disgust but
performed as well as control subjects for happy and angry faces. Similar-
ly, Unoka, Fogd, Füzy, and Csukly (2011) investigated patterns of accu-
racy and error in emotion recognition using the Ekman 60 Faces test in
33 BPD inpatients (29 females) and 32 (30 females) matched healthy con-
trols; BPD individuals did not demonstrate impairments in recognizing
happy emotions, but did show reduced accuracy in discriminating nega-
tive emotions as well as a tendency to overattribute surprise and disgust
and underattribute fear, compared with the control subjects. Conversely,
in a sample of 11 females with BPD and 9 nonclinical female controls,
Merkl et al. (2010) assessed facial expression recognition using Ekman’s
(1993) stimuli set and reported superior performance of borderline sub-
jects in identifying fear.
Two of the articles investigating emotion recognition studied the rela-
tionship of these skills to borderline personality features in nonclinical
populations; this kind of sampling method is particularly useful in reveal-
ing the skills and deficits associated with a borderline personality profile
in the absence of significant interpersonal impairment. In a sample of 150
adults sampled from university students and the wider community (70%
female), Gardner, Qualter, Stylianou, and Robinson (2010) reported a sig-
nificant interaction between borderline features and executive control
with respect to decoding angry facial expressions, such that high border-
line features combined with low executive control predicted poor recogni-
THE BORDERLINE EMPATHY PARADOX 9
tion of angry faces while high borderline features and high executive con-
trol predicted enhanced recognition of angry faces. Executive control
describes the ability to regulate attentional resources and is often im-
paired in psychiatric patients, including individuals with a BPD diagnosis
(Ayduk et al., 2008). The interaction of borderline features with decreased
attentional resources may thus be responsible for mediating deficits in
emotion recognition in BPD.
SELF-REPORTED EMPATHY
Two studies examined self-reported empathy in individuals with BPD
using the Interpersonal Reactivity Index (IRI; Davis, 1980, 1983). Em-
ployed extensively in personality research, the IRI is a multidimensional
self-report measure of empathy assessing the related but dissociable
cognitive and affective components of empathic skill across four sub-
scales: perspective taking; fantasy; empathic concern; and personal
distress. Using this instrument, Guttman and Laporte (2000) reported
reduced cognitive empathy and increased affective empathy in 27 fe-
males with BPD relative to clinical and nonclinical control subjects. In a
sample of 20 individuals with BPD (18 females), Harari et al. (2010)
found significantly reduced cognitive empathy but comparable levels of
affective empathy in individuals with BPD relative to nonclinical con-
trols.
EMOTIONAL INTELLIGENCE
Four studies have measured emotional or personal intelligence in BPD; in
these studies, the definitions of personal and emotional intelligence de-
scribe essentially identical skills. For example, emotional intelligence de-
scribes the capacity to perceive, understand, and regulate emotion in ad-
dition to using emotions to facilitate mental processes (Mayer & Salovey,
1997). Personal intelligence involves the ability to access one’s emotions
as well as the ability to perceive and distinguish among another person’s
motivations and intentions (Gardner, 1983).
Prompted by clinical accounts of the borderline empathy paradox, Park,
Imboden, Park, Hulse, and Unger (1992) hypothesized that borderline in-
dividuals are endowed with enhanced personal intelligence that could in-
teract with abusive childhood environments to play a key causal role in
the development of BPD. To test this idea, the authors evaluated the per-
sonal intelligence and history of past abuse of 23 borderline patients (18
females) from their own clinical work and 38 outpatients with other per-
sonality disorder diagnoses. For the purpose of this study, Park et al.
(1992) derived a rough scale of personal intelligence from Gardner’s (1983)
research. Patients were categorized as “gifted” in the domain of personal
intelligence if they clearly demonstrated at least three of the following: (1)
intense preoccupation with and/or access to feelings of self and others; (2)
10 DINSDALE AND CRESPI
at least three perceptive observations about other people as expressed
during therapy sessions; (3) evidence of empathic concern; and (4) the ab-
sence of pervasive envy, grandiosity, or devaluation of others. Preoccupa-
tion with feelings was included because the authors reasoned that if indi-
viduals with BPD are indeed endowed with emotional giftedness, but these
abilities are not realized due to poor environments, the giftedness may
manifest as a drive to access and understand emotions. The authors re-
ported that 74% of the borderline patients demonstrated both enhanced
personal intelligence and a history of abuse, significantly greater than the
13% of the nonborderline controls. Though intriguing, these results must
be interpreted cautiously because of the lack of independent validation for
their method of assessing personal intelligence and the potential for clini-
cian bias.
Beblo et al. (2010) assessed emotional intelligence in a sample of 19 bor-
derline patients (16 females) and 20 nonclinical control subjects (17 fe-
males) using the Mayer-Salovey-Caruso emotional intelligence test (MSCEIT;
Mayer, Salovey, & Caruso, 2002) and the Test of Emotional Intelligence
(TEMINT; Schmidt-Atzert & Buehner, 2002). These tests assess perfor-
mance in four domains of emotional intelligence (perceiving, understand-
ing, and regulating emotion, and applying emotions to mental processes)
across a variety of tasks. No difference between BPD individuals and con-
trol subjects was found for any domain of emotional intelligence. Using
only the MSCEIT, Hertel, Shütz, and Lammers (2009) assessed emotional
intelligence performance in 19 female borderline patients as well as other
clinical and nonclinical individuals and reported a reduced overall emo-
tional intelligence score of the borderline group relative to the nonclinical
control group. Specifically, the borderline patients were reduced in their
ability to understand emotional information and to regulate emotions, but
they performed as well as the nonclinical controls in perceiving emotions
and using emotions to facilitate thought. In contrast to Beblo et al. (2010),
Hertel et al. (2009) did not control for general intelligence and therefore
the reduced emotional intelligence performance of the BPD patients may
be attributable to group differences in cognitive ability. Variation in bor-
derline symptom severity may also differentially affect emotional intelli-
gence ability in these two studies, but there is insufficient data to evaluate
this claim.
In a nonclinical sample of 523 adults (78% female), Gardner and Qual-
ter (2009) studied the relationship of borderline personality features to
both trait and ability emotional intelligence using the Schutte Emotional
Intelligence Scale (SEIS; Schutte et al., 1998) and the MSCEIT, respec-
tively. Most of the assessed borderline personality features negatively pre-
dicted MSCEIT scores for the abilities of understanding, managing, and
facilitating emotions. The ability to perceive emotions was not related to
BPD features. The overall SEIS score, which measures the trait-based
ability to manage, perceive, and utilize emotions, was negatively related to
borderline features.
THE BORDERLINE EMPATHY PARADOX 11
MENTALIZATION USING PASSIVE STIMULI
Given the recent interest in mentalization-based approaches to treating
BPD (Fonagy & Luyten, 2009) and the availability of instruments from
autism research for assessing theory of mind skills, recent work has be-
gun to assess “mindreading” skills in borderline populations. Results from
these five studies are mixed. For example, using Happé’s Advanced Theory
of Mind Test, Arntz, Bernstein, Oorschot, and Schobre (2009) assessed
mentalizing skills in 16 female patients with BPD, 16 female patients with
cluster-C personality disorder diagnoses, and 28 female nonclinical con-
trol subjects; study participants were matched for both age and intelli-
gence. The test was translated into Dutch for the purpose of the Arntz et
al. study and included stories involving white lies, persuasion, bluffs, and
mistakes in addition to nonmental stories for control purposes. After hear-
ing the stories, individuals were asked questions about the characters’
mental states. Patients with BPD performed significantly better than the
healthy controls, although cluster-C patients had the highest scores over-
all.
Ghiassi, Dimaggio, and Brune (2010) studied mentalizing and parent-
rearing behavior in 50 borderline patients (46 females) and 20 nonclinical
control subjects (13 females) using two mental state attribution tasks that
have been employed in psychoses research: the Mental State Attribution
Task-Sequencing and the Mental State Attribution Task-Questionnaire
(MSAT-S and MSAT -Q; Brüne, 2005). Individuals were asked to logically
sequence a variety of cartoon pictures into coherent stories and then an-
swer first, second, and third order mentalizing questions about the char-
acters’ beliefs and intentions. The authors did not control for intellectual
functioning, and the control group had a significantly higher proportion of
males than did the patient group. Performance on the mentalizing tasks
did not differ between the patients and the controls, and sex showed no
effects on mentalizing ability; however, the authors did find that higher
levels of maternal rearing behavior that involved rejection and punishment
were associated with lower mentalizing ability in the BPD patients only.
Preißler et al. (2010) assessed social-cognitive skills in 64 females with
BPD and 38 nonclinical female subjects using two tasks: the “Movie for
Social Cognition” (MASC; Dziobek et al., 2006) and the “Reading the Mind
in the Eyes” Test (RMET; Baron-Cohen, Wheelwright, Hill, Raste, & Plumb,
2001). The MASC involves watching a film and then assessing the emo-
tions, thoughts, and mental states of the characters, providing multidi-
mensional social-cognitive stimuli that can detect subtle difficulties in
mentalizing abilities. The RMET asks individuals to infer mental states
from the eye regions of photographed faces, and it has been shown to reli-
ably discriminate between people with and without high-functioning au-
tism. For the MASC, Preißler et al. (2010) found that borderline patients
demonstrated reduced skill relative to healthy controls, while the RMET
results suggested comparable skills in both groups. Consistent with some
12 DINSDALE AND CRESPI
of the facial expression recognition research, Preißler et al. (2010) argued
that the higher sensitivity of the MASC reveals a reduction in the ability of
individuals with BPD to integrate complex social information, especially
when time is constrained. In contrast, Fertuck et al. (2009) reported high-
er RMET scores in 30 individuals with BPD (26 females) relative to 25
control subjects (15 females), and Frick et al. (2012) reported higher RMET
scores in 21 females with BPD compared with 20 control females. These
divergent findings cannot easily be attributed to differences in intellectual
functioning, because Preißler et al. (2010) matched the controls and bor-
derline individuals on fluid IQ, and Fertuck et al. (2009) and Frick et al.
(2012) matched their control and borderline groups by education level.
Prei ßler et al. (2010) pointed out, however, that the increased proportion of
males in the Fertuck et al. (2009) control group may have reduced control
scores to a lower end of the range than is normally reported in control sub-
jects, and therefore increased the probability of detecting group differences.
Scott, Levy, Adams, and Stevenson (2011) assessed mental state attri-
bution as a function of borderline traits using the RMET in a nonclinical
sample of undergraduate students. Based on a modified version of the
McLean Screening Instrument for BPD (MSI-BPD; Zanarini et al., 2003),
46 subjects (31 females) were assigned to the low-borderline condition
and 38 subjects (25 females) were assigned to the high-borderline condi-
tion. The authors reported no difference in mental state decoding ability
between the two groups for positive or neutral RMET stimuli, but for nega-
tive stimuli, the high-BPD group performed better than the low-BPD
group. This difference was not attributable to group differences in re-
sponse bias or affective state.
In addition to the empathy data discussed in the previous section, Ha-
rari et al. (2010) studied cognitive and affective components of theory of
mind skills in the same study using the Faux-Pas Task (Baron-Cohen,
O’Riordan, Stone, Jones, & Plaisted, 1999). In this task, cognitive theory
of mind represents the understanding that within an interaction, a speak-
er and listener have different mental states. The affective component taps
into a participant’s appreciation of the emotional impact of a speaker’s
statement on a listener. Individuals listen to 20 stories and then answer
questions that are designed to test their ability to detect a faux pas. The
borderline patients were impaired in their detection and cognitive under-
standing of a faux pas relative to the control subjects, but performed
equally well in their affective understanding. Based on the combined re-
sults of both the Faux-Pas Task and the IRI, Harari et al. (2010) concluded
that control subjects demonstrate higher cognitive empathy relative to af-
fective empathy while patients with BPD show the reverse pattern.
MENTALIZATION USING INTERACTIVE STIMULI
Two studies have assessed borderline empathy in real social interactions
between individuals with and without BPD. In a clinical setting, Ladisich
THE BORDERLINE EMPATHY PARADOX 13
and Feil (1988) had 20 borderline patients and 39 nonborderline psychiat-
ric patients interact with one another and subsequently report on the feel-
ings and qualities of themselves and other group members, using the
Giessen Test (GT; Beckmann & Richter, 1972) and the Unpleasant Person
Hierarchy Test (UPHT), a task designed specifically for this study. The
composition of sex in the study groups was not reported. Empathic accu-
racy was assessed by comparing how closely perceivers could predict the
self-ratings of other group members. Patients with BPD were more accu-
rate in inferring the feelings of other patients than all other study sub-
jects, including the participating psychiatrist.
Flury, Ickes, and Schweinle (2008) assessed the association between
borderline personality features and empathic accuracy in a sample of 76
undergraduate students (46 females) recruited from a larger sample of
students who completed the Borderline Syndrome Index (BSI; Conte, Plut-
chik, Karasu, & Jerrett, 1980); only those individuals scoring in the upper
and lower quartiles were included. Using a paradigm developed by Ickes
(1993) and similar to Ladisich and Feil’s study, Flury et al. (2008) esti-
mated empathic accuracy by measuring each subject’s ability to infer the
thoughts and feelings of a partner in dyadic interactions between one
high-borderline individual and one low-borderline individual. The authors
reported significantly increased accuracy in ratings of the high-borderline
group relative to the low-borderline group. To test for alternative explana-
tions for this difference, the authors statistically controlled for stereotypi-
cal responding style and found that the borderline advantage disappeared,
although there was no significant difference in stereotypical responding
between the two groups. After further analyses, the authors concluded
that low-borderline participants tended to project their own personality
characteristics onto those of their interaction partner, resulting in higher
error rates due to the more unusual personality profile of the high-border-
line subjects. Conversely, the high-borderline participants accurately as-
sumed that their more atypical personality was not generalizable to their
partner, and were therefore more accurate in their ratings. The authors
concluded that the borderline advantage was attributable to differences in
partner “readability” and not empathic skill. These novel results provide
an alternative interpretation of borderline empathy and also indicate the
possibility of enhanced self-insight in individuals with borderline person-
ality features.
In a third study using interactive stimuli, Franzen et al. (2011) com-
pared the mentalizing processes of 30 BPD patients (22 females) with 30
nonpatients in a simulated social interaction game developed for research
in behavioral economics and decision making. In a multiround virtual
trust game involving monetary unit exchanges between human and vir-
tual (computer-screen) players, the researchers were able to experimen-
tally manipulate the fairness and emotional cues exhibited by virtual play-
ers as well as the congruency between cues and actual behavior. For some
rounds of the game, players’ emotional cues signaled fair behavior (i.e.,
14 DINSDALE AND CRESPI
smiles) while in other rounds the cues were inconsistent with level of fair-
ness. The authors found that participants with BPD adjusted their playing
strategy according to the objective fairness rather than the emotional cues
of the virtual players. This finding could not be explained by group differ-
ences in emotion recognition or perceived fairness because both border-
line patients and control subjects assessed these elements comparably.
These authors concluded that individuals with BPD may thus process so-
cial information in a more controlled and deliberate manner, whereas con-
trol individuals may process emotional cues, especially salient facial ex-
pressions, more automatically.
DISCUSSION
This review and synthesis has assessed the evidence for the borderline
empathy phenomenon across a range of empathic skills. The degree to
which empathic abilities are enhanced, comparable, or reduced among
individuals with BPD compared to controls was highly variable across
studies. However, a sufficient number of studies (14) and different tests (8)
showed enhanced empathic skills in BPD to indicate that this phenome-
non is worthy of further attention, and additional research effort designed
to explain both the causes of borderline empathy and the among-study
variation in results.
One possible cause of variation in results among studies is the nature of
the empathic test deployed. Thus, in all three studies where empathic
skills were examined in interactive social environments, individuals with
BPD demonstrated increased abilities to accurately infer mental states
and respond appropriately to the behavior of others, relative to control
subjects (Flury et al., 2008; Franzen et al., 2011; Ladisich & Feil, 1988).
By contrast, in tasks requiring mental state attributions from passive
stimuli, individuals with BPD demonstrated enhanced skills in three tests
from four studies (Happé’s Advanced ToM test, Arntz et al., 2009; RMET
for negative emotions only, Scott et al., 2011; overall RMET score, Fertuck
et al., 2009 and Frick et al., 2012), conserved skills for three tests from
four studies (MSAT, Ghiassi et al., 2010; affective understanding of faux
pas, Harari et al., 2010; RMET, Preißler et al., 2010; RMET for positive
and neutral emotions, Scott et al., 2011), and reduced skills for two tests
from two studies (cognitive understanding of faux pas, Harari et al., 2010;
MASC, Preißler et al., 2010). This apparent contrast in results between
studies using interactive and passive stimuli suggests that interactive
stimuli may be relatively more sensitive in demonstrating the skills of in-
dividuals with BPD, and therefore highlights the need for future research
to examine borderline social cognition through interactive study environ-
ments and relatively realistic social interactions.
For other categories of empathic skills, results were notably mixed. As-
says of emotional intelligence suggested enhanced, reduced, or conserved
abilities in borderline subjects (Beblo et al., 2010; Hertel et al., 2009; Park
THE BORDERLINE EMPATHY PARADOX 15
et al., 1992). This variation in reported emotional intelligence may vary, in
part, as a function of borderline symptom severity or overall cognitive abil-
ity. Taken together, findings from facial expression recognition studies
suggest that borderline individuals may have an increased sensitivity to
negatively valenced emotional stimuli, and that factors such as reduced
executive control may impair performance, especially in tasks requiring
quick responses. Given that psychopathology is almost always associated
with reduced performance in facial affect recognition (for one exception in
schizophrenia research, see Davis & Gibson, 2000), the observation of en-
hanced borderline performance in four studies is especially noteworthy.
Studies comparing cognitive and affective empathic skills in BPD re-
vealed a consistent and interesting pattern. Harari et al. (2010) reported
reduced cognitive empathy but conserved affective empathy among indi-
viduals with BPD for measures assessing both empathizing and mental-
izing abilities. Control subjects were characterized by higher cognitive em-
pathy relative to affective empathy, whereas individuals with BPD
demonstrated the reverse pattern; given that the groups were matched for
intellectual functioning, this pattern could not be attributed to group dif-
ferences in intelligence. Similarly, Guttman and Laporte (2000) reported
reduced cognitive empathy and enhanced affective empathy in individuals
with BPD relative to control subjects. These studies are limited in that the
ability of borderline subjects to accurately rate their own empathic skills
is unknown, so results warrant a conservative interpretation. Given that
both studies reported reduced cognitive empathy and either normal or
enhanced affective empathy, it is possible that borderline empathy is
characterized by a dissociation or asymmetry between these different fac-
ets of empathic skill (Harari et al., 2010).
Empathic deficits are often implicated as etiologically central to psycho-
pathology, due to the impaired social functioning characteristic of indi-
viduals with psychiatric diagnoses (Cameron, 2009). Indeed, a substantial
body of literature indicates reduced social competency for individuals with
the Axis I disorders that share psychotic-affective symptoms with BPD,
including major depression, bipolar disorder, and schizophrenia (e.g.,
Barnow et al., 2010; Glaser, Van Os, Thewissen, & Myin-Germeys, 2010;
Hooley, 2010; Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004; Perugi,
Fornaro, & Akiskal, 2011). Although it is reasonable to assume that social
interactions are facilitated through the effective use of both basic empath-
ic skills such as emotion recognition and more complex skills such as
mental state attribution, impairments to overall social functioning may, in
principle, result from either reductions or increases in specific abilities
from normative levels (Crespi & Badcock, 2008; Montag et al., 2010; Sharp
et al., 2011). For example, Langdon, Corner, McLaren, Coltheart, and
Ward (2006) studied attentional orienting as a function of gaze shifting in
people with and without schizophrenia and found that individuals with
schizophrenia were hyperresponsive to gaze, reflexively shifting their at-
tention in the direction indicated by another’s gaze at a lower threshold
16 DINSDALE AND CRESPI
than did subjects without schizophrenia. This automatic and increased
sensitivity to gaze may be linked to the tendency of individuals with schizo-
phrenia to overperceive intentionality and experience paranoia, both of
which may contribute to the social difficulties observed in schizophrenia.
Similarly, excessive levels of empathy may potentiate or exacerbate de-
pression, anxiety, and borderline features, especially among females
(Dammann, 2003; O’Connor et al., 2007; Zahn-Wexler, Crick, Shirtcliff, &
Woods, 2006; Zahn-Wexler, Shirtcliff, & Marceau, 2008). The observation
of general social deficits in individuals with psychotic-affective conditions
is thus not necessarily sufficient to indicate reductions in the empathic
skills that underlie social functioning, because such deficits could result
from qualitatively distinct alterations. Whether alterations involve reduc-
tions or enhancements in specific empathic domains may thus be useful
in forming hypotheses for the causes of these conditions. But how might
enhanced empathic abilities be related to severe deficits in interpersonal
functioning in BPD?
RESOLVING THE BORDERLINE EMPATHY PARADOX
Psychoanalytic accounts attribute borderline empathy to environmental
causes, such that in response to inconsistent or neglectful parenting and
in an effort to maintain a constant view of the caregiver object, the border-
line individual develops enhanced sensitivity to the subtle, subconscious
cues indicating the mental states of the parent (Carter & Rinsley, 1977;
Krohn, 1974). The tendency to perceive and respond to subconscious
drives, combined with a learned distrust of conscious behavior, thus dis-
rupts the ability of the borderline individual to develop enduring and sta-
ble experiences of others in interpersonal contexts, which leads to lasting
social dysfunction. This model is supported by evidence suggesting a rela-
tionship between maternal neglect and enhanced nonverbal decoding
abilities, whereby increased reports of maternal neglect positively predict-
ed scores on the PONS in borderline subjects (Frank & Hoffman, 1986).
Linehan (1993) similarly proposed that BPD is characterized by a height-
ened sensitivity to, and keen awareness of, emotional cues, especially neg-
ative cues signaling rejection or abandonment, in the social environment.
The origins of this enhanced sensitivity are suggested to be biological in
nature, although emotionally invalidating environments—such as the
childhood abuse and neglect that is often reported in BPD cases—are ex-
pected to exacerbate innate empathic sensitivity. Under this hypothesis,
the social difficulties characteristic of BPD result from low thresholds of
emotional reactivity and insecure appraisals of emotional events based on
accurate perceptions of social cues (Wagner & Linehan, 1999).
Park et al. (1992) also attributed borderline empathy and its role in BPD
development to interacting biological and environmental factors, although
these researchers emphasized the positive aspects of enhanced empathic
skills and referred to them as cognitive “gifts” involving the desire and
THE BORDERLINE EMPATHY PARADOX 17
ability to understand the thoughts and feelings of others, which, in the
absence of abuse, would contribute to an individual’s well-being and not
result in BPD. Fertuck et al. (2009) suggested that enhanced mentalizing
in BPD engenders reduced interpersonal functioning through a combina-
tion of negative expectations upon entering social interactions and re-
duced executive cognitive control, resulting in the inability to modify in-
correct appraisals of social situations. Similarly, Arntz et al. (2009)
suggested that impulsivity, emotional reactivity, and working memory def-
icits observed in BPD may inhibit the borderline individual’s ability to ap-
ply intact mentalizing skills in emotionally charged situations, therefore
contributing to social dysfunction.
Drawing from the reviewed studies, we suggest that the borderline em-
pathy paradox may be attributable in part to a combination of enhanced
attention to, and perception of, social stimuli with dysfunctional process-
ing. Under this model, many individuals with BPD may exhibit increased
attention to social stimuli, and thus develop an enhanced ability to per-
ceive social information. Such enhanced attention and perception may
become pathological if they interact with deficits in other domains such as
attentional control, emotion regulation, and regulation of the attachment
system, such that the inferences drawn from social information become
amplified and distorted toward negative, self-referential emotional states.
This model is consistent with previous evidence of hypersensitivity to the
social environment in BPD (Goodman & Siever, 2011; Gunderson & Ly-
ons-Ruth, 2008; Lynch et al., 2006), which involves constant vigilance to
anticipated rejection (Fertuck et al., 2009) and difficulties in regulating
emotion due to low thresholds for stress-related activation of the attach-
ment system and deactivation of controlled mentalization (Fonagy, Luy-
ten, & Strathearn, 2011). Such stress- and emotion-mediated deactiva-
tion of controlled mentalization should be unlikely to reduce performance
on the laboratory-based empathic-skill tests analyzed here, which could
help to explain preservation of empathic abilities in individuals with BPD
but cannot explain enhancements. High sensitivity and attention to social
cues may also engender hypermentalizing (overly complex inferences
based on social cues), which can interact in a vicious cycle with dysregu-
lated emotionality through anxious, uncontrolled rumination (Sharp et
al., 2011). Finally, to the extent that conscious or unconscious mental
states of social interactants indeed reflect negatively upon individuals
with BPD but remain verbally unexpressed, highly sensitive and accurate
empathic inferences that reveal such states may also exacerbate BPD
symptoms by instigating emotional dysregulation and dysfunctional inter-
actions. This model based on enhanced attention to, and perception of,
social stimuli in BPD is conceptually analogous to models of autism spec-
trum disorders, where increases have been observed in attention to, and
perception of, nonsocial compared to social stimuli (Baron-Cohen, Ash-
win, Ashwin, Tavassoli, & Chakrabarti, 2009; Klin, Lin, Gorrindo, Ram-
say, & Jones, 2009; Mottron & Burack, 2001; Mottron, Dawson, Souli-
18 DINSDALE AND CRESPI
eres, Hubert, & Burack, 2006; Pierce, Conant, Hazin, Stoner, & Desmond,
2011).
Findings from Gardner et al. (2010) and Lynch et al. (2006) are also
consistent with this general model for helping to explain the borderline
paradox. Thus, in the former study, BPD traits predicted enhanced recog-
nition of anger, but only when executive control was also high; in the
latter study, individuals with BPD correctly identified the emotion of mor-
phing facial expressions earlier than did healthy controls, suggesting en-
hanced perception of emotional cues. The dissociation between cognitive
and affective empathy observed by Harari et al. (2010) and Guttman and
Laporte (2000) may also be concordant with the model, in that affective
empathy may be more closely linked to the automatic and immediate per-
ception of social-emotional cues and accompanying physiological respons-
es, whereas cognitive empathy involves higher order cognitive functions
(Shamay-Tsoory, 2011). Borderline empathy may thus involve dysregula-
tion to the integrated social cognitive-affective system, resulting in a char-
acteristic asymmetry or splintering of empathic skills (Fonagy et al., 2011).
Gaining an understanding of the specific pattern of cognitive-affective en-
hancements and reductions in individuals with BPD, and their interac-
tions with social attention and perception, attentional control, and emo-
tion regulation, should clarify the relationship between borderline and
normal social cognition, as well as elucidate the role of enhanced empathy
in BPD etiology and symptoms.
Also salient to a model of BPD involving, in part, a maladaptive en-
hancement of attention to social stimuli is evidence for enhanced perfor-
mance of individuals with BPD on tasks that typically demonstrate female
superiority in nonclinical populations, and corresponding reduced perfor-
mance in tasks with a male advantage (Table 1). It is important to note
that most tasks in Table 1 are linked to a female advantage, given that
overall females appear to outperform males in the general domain of social
cognition (i.e., Geary, 2010). Females thus outperform males in facial
emotion recognition for a variety of tasks and stimuli (reviewed in Geary,
2010); four studies reported superior performance of borderline subjects
in this domain (Gardner et al., 2010; Lynch et al., 2006; Merkl et al.,
2010; Wagner & Linehan, 1999). For self-reported affective empathy as-
sessed by the IRI (Davis, 1980, 1993), Guttman and Laporte (2000) re-
ported enhanced scores for borderline patients relative to controls while
Harari et al. (2010) reported no difference. Studies using the IRI in non-
clinical samples of both adolescents and adults have found a female ad-
vantage in the subscales composing the affective empathy score (Berthoz,
Wessa, Kedia, Wicker, & Grezes, 2008; Mestre, Samper, Frias, & Tur,
2009). Females also outperform males on tasks requiring the attribution
of mental states from photographs of the eyes (RMET; Baron-Cohen, Jol-
liffe, Mortimore, & Robertson, 1997; Baron-Cohen et al., 2001). For this
task, Preißler et al. (2010) found no group differences whereas Fertuck et
al. (2009) and Frick et al. (2012) reported enhanced performance of the
THE BORDERLINE EMPATHY PARADOX 19
borderline subjects relative to non-BPD controls. Scott et al. (2011) re-
ported higher RMET scores for negative emotional stimuli in healthy
adults with borderline personality features compared to adults without
borderline personality features.
For higher order theory of mind tasks, female superiority is often as-
sumed, although performance of the sexes is dependent on the specific
task employed. For example, Russell, Tchanturia, Rahman, and Schmidt
(2007) reported a male advantage for Happé’s cartoon task, but Bosacki
(2000) reported female superiority on a similar task in healthy preadoles-
cents. With respect to BPD, Arntz et al. (2009) found enhanced perfor-
mance of the borderline group relative to nonclinical control subjects on
Happé’s (1994) Advanced ToM task. Interpretation of these results is se-
verely limited by the relative lack, or absence, of male subjects in most
studies of BPD. Future research would benefit from comparing male and
female performance in both borderline and nonclinical populations in or-
der to advance understanding of borderline phenotypes in the context of
sex differences in social cognition.
CONCLUSIONS
By critically examining the evidence bearing on enhanced empathic skills
in borderline populations, we have provided the groundwork for future
tests of hypotheses concerning both the causes of borderline empathy and
the role of empathic enhancements in BPD etiology, symptoms, and ther-
apy. Given the evidence regarding the borderline empathy phenomenon,
we have suggested that the causal bases underlying BPD may involve, in
part, a pathological and selective enhancement of normally adaptive em-
pathic abilities, especially with regard to increased attention to social
stimuli. More generally, increased understanding of the role that social
brain adaptations play in mediating human psychiatric disease risk may
help to explain maladaptations of human social interactions, especially for
conditions such as borderline personality disorder that centrally involve
interpersonal relationships.
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Introduction This chapter describes the intimate connection between empathy and depression, the epidemic of our modern world. While depression has been described as a ‘disorder of the self’, it may be more accurately characterized as a disorder of ‘concern for others’. People who are depressed most often have normal or elevated levels of empathy; however, their affect-directed, automatic causal interpretations of pain in others are often disturbed, leading to non-conscious assertions of blame, usually placed on themselves. Empathy, a socially organizing neural system, allows us to share others' feelings, to mimic without awareness, and forms the basis of our relationships and our social learning (Decety & Jackson, 2004). A sophisticated Theory of Mind (ToM), or the ability to know what others are thinking, is sometimes considered a prerequisite for true empathy. The capacity for empathy, present in infants from the first days of life, may be independent of cognitive maturity and a developed ToM. Healthy empathy, however, requires an understanding of causality, undeveloped in very young children and affectively distorted in depression. The empathic reaction in depressives often leads to great distress because they tend to unrealistically blame themselves for pain felt by others. Thus, in mood disorders, the empathy system may be functional; however, an overly active and automatic moral system, connected to the empathic experience, tends to misinterpret attribution, and the guilt felt at believing that you have caused pain in another leads to empathic distress, an exaggerated reaction. © Cambridge University Press 2007 and Cambridge University Press, 2009.
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This clinical study of 23 borderline outpatients and 38 outpatients with other personality disorders provides evidence that individuals who become borderline frequently have a special talent or gift, namely a potential to be unusually perceptive about the feelings of others. We postulate that this talent is derived from an innate characteristic rather than simply arising from early environmental influences. We also present evidence that chronic, severe, pervasive psychological abuse, or 'mind abuse,' is the most frequent and significant form of caretaker abuse (vs. sexual or physical) in the childhood histories of this disorder. Our data support the hypothesis that the interaction of a child's gifted characteristics with this abuse creates a tragic drama that is etiological for BPD in a substantial number of cases. We propose that the abuse markedly perverts not only use of the perceptual talents (e.g., powerfully compelling projective identification) but overall psychological development. We discuss how these issues are relevant to the conduct of effective therapy.
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