Personality Functioning and Mentalizing in Patients With Subthreshold or Diagnosed Borderline Personality Disorder: Implications for ICD-11

Abstract

The 11th revision of the International Classification of Diseases for Mortality and Morbidity Statistics (ICD-11) defines personality disorder according to personality functioning, which relates to self- and interpersonal functioning. The aim of the present study was to assess the relationship between mentalizing and personality functioning in patients with subthreshold or diagnosed borderline personality disorder. A total of 116 eligible participants were included. Mentalizing was assessed using the Mentalization Questionnaire (MZQ), personality functioning (self- and interpersonal functioning) was assessed using the Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF), and borderline severity was assessed using the Zanarini Rating Scale (ZAN-BPD). Mediation analysis was employed to test if mentalizing accounted for the relationship between borderline severity and self- and interpersonal functioning. We found a significant relationship between borderline severity and both subscales of the LPFS-BF. Mentalizing fully and significantly mediated the relationship between borderline severity and interpersonal functioning. However, mentalizing only partly mediated the relationship between borderline severity and self-functioning. Controlling for the covariates gender and age did not impact the results. Mentalizing is likely to be involved in the ICD-11 model of personality functioning, especially interpersonal functioning. This could emphasize the relevance of therapy aimed at strengthening mentalizing abilities when treating personality pathology in general and people with borderline personality disorder in particular. However, self-functioning may be more nuanced, as aspects other than mentalizing also influence self-functioning. The study is explorative in nature and has methodological limitations that require caution in the interpretation and generalizability.

Impairments in Cognitive and Emotional Empathy as Markers of General versus Specific Personality Pathology

“…Thus, higher levels of general personality pathology are accompanied by more difficulties in mentalizing emotions of others. This finding complements existing evidence on associations between mentalizing and personality functioning [13][14][15]. The results are all the more compelling because they show that impairments in cognitive empathy are linked not only to general personality pathology in the form of personality functioning, which conceptually has a strong link to cognitive empathy, but also to general personality pathology based on the models of pathological personality traits and DSM-5 Section II PDs, both of which conceptually only contain scattered references to deficits in cognitive empathy.…”

“…Accordingly, a study found that clinician-assessed mentalizing and personality functioning were highly correlated with each other, while empathy was the domain with the highest association with mentalization [13]. Associations between mentalization and personality functioning could also be found when using self-reports [14, 15]. Furthermore, a study found that impairments in personality functioning, assessed with the Operationalized Psychodynamic Diagnosis System [16], were highly associated with deficits in self-reported trait emotional intelligence [17], which entails aspects of emotional empathy.…”

The interplay of Criterion A of the Alternative Model for Personality Disorders, mentalization and resilience during the COVID-19 pandemic

“…Another construct related to personality functioning is mentalization, the capacity to elaborate on other people's state of mind and intentions (Bateman and Fonagy, 2004;Luyten et al, 2020). Mentalization was found to overlap conceptually and operationally with Criterion A (Bender et al, 2011;Zettl et al, 2020;Rishede et al, 2021). Furthermore, fostering social cognition competences by improving mentalization capacities is a common element in all therapies of borderline personality disorder (BPD; Bateman and Fonagy, 2004;Viviani et al, 2011;Fischer-Kern et al, 2015;Buchheim and Diamond, 2018;Fonagy et al, 2019;Labek et al, 2019;Lüdemann et al, 2021).…”

The impact of outcome expectancy on therapy outcome in adolescents with borderline personality disorder

“…Assuming personality pathology, mentalizing capacity and personality functioning as related concepts, a significant relationship between severity of borderline symptomatology and interpersonal functioning mediated by mentalizing capacity was found [ 86 ]. Early intervention in patients with low treatment expectancy might focus on mentalization capacity to improve interpersonal functioning, which could increase treatment expectancy.…”