Comorbidity and Overlaps between Autism Spectrum and Borderline Personality Disorder: State of the Art

Despite the relationship between Autism spectrum disorder (ASD) and personality disorders (PD) still being scarcely understood, recent investigations increased awareness about significant overlaps between some PD and autism spectrum conditions. In this framework, several studies suggested the presence of similarities between BPD and ASD symptoms and traits, based on the recent literature that increasingly reported increased comorbidity rates and significant symptomatologic overlaps between the two conditions. The aim of this review is to describe the available studies about the prevalence of the association between different forms of autism spectrum (full-fledged clinical conditions as well as subthreshold autistic traits) and BPD. Despite some controversial results and lack of homogeneity in the methods used for the diagnostic assessment, the reviewed literature highlighted how subjects with BPD reported higher scores on tests evaluating the presence of AT compared to a non-clinical population and hypothesized the presence of unrecognized ASD in some BPD patients or vice versa, while also describing a shared vulnerability towards traumatic events, and a greater risk of suicidality in BPD subjects with high autistic traits. However, the specific measure and nature of this association remain to be explored in more depth.

A meta-analysis of theory of mind and 'mentalization' in borderline personality disorder: a true neuro-social-cognitive or meta-social-cognitive impairment?

BACKGROUND

It is widely accepted that borderline personality disorder (BPD) is associated with significant impairments in mentalization and theory of mind (ToM) which are considered as closely related concepts by many authors particularly in psychoanalytical circles. However, for understanding interpersonal difficulties in personality disorders, it is important to distinguish neuro-social cognitive impairment from the abnormal meta-social-cognitive style of patients.

METHODS

The current systematic review aimed to conduct separate meta-analyses of 'mentalization' [reflective functioning (RF] and different aspects of ToM in BPD. A literature search was conducted to locate relevant articles published between January 1990 to July 2021. Random-effect meta-analyses were conducted in 34 studies involving 1448 individuals with BPD and 2006 healthy controls.

RESULTS

A very large impairment in RF was evident in BPD [d = 1.68, confidence interval (CI) = 1.17-2.19]. In contrast, ToM impairment was modest (d = 0.36, CI = 0.24-0.48). BPD patients underperformed healthy controls in ToM-reasoning (d = 0.44, CI = 0.32-0.56) but not ToM-decoding. Increased HyperToM (d = 0.60, CI = 0.41-0.79) and faux pas recognition (d = 0.62, CI = 0.35-0.90) errors in BPD compared to healthy controls were most robust ToM findings in this meta-analysis.

CONCLUSIONS

BPD is characterized by very severe deficits in RF and modest and selective abnormalities in ToM. Interpersonal problems and difficulties in processing social information in BPD can be best explained by patients' maldaptive meta-social cognitive style and top-down effects of these abnormalities rather than having a primary neuro-social cognitive deficit.

Cognitive and Affective Theory of Mind in Female Patients With Borderline Personality Disorder

Empirical studies have identified deficits in cognitive and affective theory of mind (ToM) in patients with borderline personality disorder (BPD), but results remain heterogeneous and not much is known about the role of childhood trauma. The current study assessed cognitive and affective ToM in 80 patients with BPD and 41 healthy controls in a false-belief cartoon task. Childhood trauma was measured with the Childhood Trauma Questionnaire (CTQ). Patients with BPD responded slower in all experimental conditions in false-belief situations, but not when false beliefs were resolved; made more errors in the cognitive ToM condition; and reported worse affective states more often in and after false-belief situations. No significant correlations between ToM and childhood trauma could be found. The current study revealed deficits in cognitive and affective ToM in patients with BPD that may be related to a more negative affective state raised by the false-belief stories.

A systematic review and meta-analysis of 'Systems for Social Processes' in borderline personality and substance use disorders

Deficits in social processing (SP) have been proposed to underpin interpersonal dysfunction in both Borderline Personality Disorder (BPD) and Substance Use Disorders (SUD). This study aimed to explore potential transdiagnostic cognitive and behavioral phenotypes of these disorders utilizing the NIMH Research Domain Criteria 'Systems for Social Processes'. A systematic review and meta-analysis of the published research was conducted on 134 studies identified through our database searches. Four meta-analyses were conducted, which revealed significant overlapping deficits in the ability to identify facial emotions and infer the mental states of others in both BPD and SUD. Further, people with BPD displayed a higher ostracism effect following perceived social exclusion. Systematically reviewed studies also revealed significant dysfunction amongst individuals with BPD and SUD across both self and other SP constructs, which were broadly similar in magnitude. Taken together, these results support the proposition that SP dysfunction may be considered a core transdiagnostic phenotype of BPD and SUD.

Dysfunction of Empathy and Related Processes in Borderline Personality Disorder: A Systematic Review

After participating in this activity, learners should be better able to:• Assess differences between adult patients with the diagnosis of borderline personality disorder (BPD) and healthy control subjects in terms of empathy and related processes• Evaluate the effects of empathy or related processes as factors contributing to abnormal social functioning in BPD ABSTRACT: We reviewed 45 original research studies, published between 2000 and 2019, to assess differences between adult patients with the diagnosis of borderline personality disorder (BPD) and healthy control subjects in terms of empathy and related processes (i.e., theory of mind, mentalizing, social cognition, and emotional intelligence). Thirty-six studies reported deficits of empathy or related processes in patients with BPD. Enhanced emotional empathy in BPD was also reported in eight studies, all of which revealed that patients had increased scores of personal distress on the Interpersonal Reactivity Index self-report questionnaire. Six studies did not find significant differences between patients with BPD and healthy control subjects in terms of empathy or related processes. No study reported enhanced cognitive empathy, social cognition, or emotional intelligence in patients with BPD. We postulate that deficits of empathy or related processes contribute to preempting the formation of stable interpersonal relationships, whereas enhanced emotional empathy might lead to personal (and interpersonal) distress, further contributing to abnormal social functioning in BPD.

Theory of mind disturbances in borderline personality disorder: A meta-analysis

Impairments of theory of mind (ToM) are widely accepted underlying factors of disturbed relatedness in borderline personality disorder (BPD). The aim of this meta-analysis a was to assess the weighted mean effect sizes of ToM performances in BPD compared to healthy controls (HC), and to investigate the effect of demographic variables and comorbidities on the variability of effect sizes across the studies. Seventeen studies involving 585 BPD patients and 501 HC were selected after literature search. Effect sizes for overall ToM, mental state decoding and reasoning, cognitive and affective ToM, and for task types were calculated. BPD patients significantly underperformed HC in overall ToM, mental state reasoning, and cognitive ToM, but had no deficits in mental state decoding. Affective ToM performance was largely task dependent in BPD. Comorbid anxiety disorders had a positive moderating effect on overall and affective ToM in BPD. Our results support the notion that BPD patients' have specific ToM impairments. Further research is necessary to evaluate the role of confounding factors, especially those of clinical comorbidities, neurocognitive functions, and adverse childhood life events. Complex ToM tasks with high contextual demands seem to be the most appropriate tests to assess ToM in patients with BPD.

Correlates of autistic traits among patients with borderline personality disorder

BACKGROUND

Despite discrete autism-related dimensions, such as deficits in communication, empathy and mentalizing are likely to affect the development of personality and despite they actually frequently occur in borderline patients, no research has so far investigated the relationship between autistic traits and Borderline Personality Disorder (BPD). The objective of this study is to investigate the clinical significance of autistic traits in subjects with BPD.

METHODS

The sample included 50 patients with a clinical diagnosis of BPD and 69 healthy controls. The Structured Clinical Interview for DSM-5 Clinician Version was used to establish the presence of comorbid mental disorders among BPD subjects and to confirm the absence of lifetime mental disorders in the control group. Participants were also asked to fill three self-report instruments: the Adult Autism Subthreshold Spectrum (AdAS Spectrum), the Autism Spectrum Quotient (AQ) and the Mood Spectrum Self-Report (MOODS-SR).

RESULTS

Patients with BPD reported higher autistic traits than healthy individuals. Moreover, autistic traits were shown to exert a significant impact on some clinical features and associated manifestation of BPD, such as suicidality and lifetime exposure to physical and/or sexual abuse.

CONCLUSIONS

Subthreshold autism spectrum may be relevant for subjects suffering from BPD and future research may further address clinical correlates of autistic traits among patients with this disorder.

Assessing advanced theory of mind and alexithymia in patients suffering from enduring borderline personality disorder

Findings on the theory of mind (ToM) abilities in borderline personality disorder (BPD) have been inconsistent. Surprisingly, no studies have focused on the complex aspects of ToM while simultaneously measuring alexithymia as well as comorbid depressive and anxiety symptoms, therefore, our study aimed to fill this gap. 30 female patients with BPD and 38 healthy controls (HCs) completed the Faux Pas Test (FPT) and the Toronto Alexithymia Scale-20 (TAS-20). The clinical and intellectual assessment comprised of the Structured Clinical Interview for DSM-IV-TR Axis II Disorders (SCID-II), the Borderline Personality Inventory (BPI), the State-Trait Anxiety Inventory (STAI), the Center for Epidemiologic Studies Depression Scale-Revised (CESD-R), and the Raven's Progressive Matrices (RPM). Women with BPD scored significantly worse than HCs on overall ToM abilities. After controlling for the intelligence level, depressive symptoms, and state and trait anxiety, both groups presented a similar overall level of alexithymia. No correlation between the FPT and TAS-20 scores was found, suggesting that both constructs might be unrelated in BPD. Because ToM dysfunctions seem not to result from comorbid clinical symptoms, trait anxiety, or intellectual abilities, our study results suggest that ToM deficits might be considered a core feature of BPD.