Stokes, Nicholas; (2001) Executive function and theory of mind in borderline personality disorder. Doctoral thesis (D.Clin.Psy), UCL (University College London).

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Abstract

Recent years have seen an increasing interest in the question of whether there may be organic as well as psychosocial factors that are important in accounting for the aetiology and symptoms of Borderline Personality Disorder (BPD). Various brain abnormalities have been reported or proposed in the disorder, particularly involving the frontal lobes, the hippocampus and the amygdala. However, the overall body of previous research has shown only mixed evidence of neuropsychological impairments associated with these brain regions in individuals with BPD. The present study investigates two cognitive functions that have been linked to the frontal lobes: executive functioning and theory of mind. Theoretical and empirical evidence from a number of sources suggests that deficits in these functions may help to account for some of the symptoms of BPD, including interpersonal difficulties, poor affect regulation, dissociation, and impulsivity. In the present study, a group of participants diagnosed with BPD (n=17) was compared to healthy controls (n=13) on a variety of executive function and theory of mind measures. These included two executive function tasks which were designed to be open-ended and to mimic real-life situations (Predicaments test, Channon and Crawford, 1999; Modified Six Elements test, Wilson et al., 1996). Such tasks may have better ecological validity than the more abstract measures of executive function which have previously been used in studies with the BPD population. The theory of mind tasks were chosen to be developmentally advanced, to enable subtle deficits in theory of mind ability to be detected (Story Comprehension test, Channon and Crawford, 2000; Happe Strange Stories test, Happe, 1994). The BPD group performed significantly worse than controls on one of the theory of mind measures (Story Comprehension test). There was no difference between the groups on the other theory of mind task (Happe Strange Stories test), but it is argued that this result may be due to the task measuring theory of mind skills at a lower level. The results of the study indicate that there may be a subtle theory of mind deficit in BPD, but this probably applies only to a proportion of individuals with the diagnosis. However further analysis underlined the possibility that this poorer theory of mind performance may be attributable to co-morbid depression rather than BPD diagnosis, and further research with a depressed control group is needed to investigate this issue properly. The theory of mind findings of the study are discussed in relation to the reflective function hypothesis of BPD. In particular, the reflective function hypothesis suggests that a deficit in theory of mind should be largely restricted to contexts which are relevant to that person's attachment history, but this study raises the possibility that the deficit may also apply to more neutral contexts. The results of the executive function measures yielded only tentative evidence for executive dysfunction BPD, a finding that fits in with the overall picture of inconsistency from previous studies. A number of possible reasons are discussed for the lack of clear findings in this area, including the small sample sizes of studies, the possibility that only sub-groups of individuals with BPD have executive difficulties, the possibility that executive dysfunction is related to emotional arousal, and the possibility that BPD is not characterised by executive dysfunction at all. Suggestions for future research into both executive functioning and theory of mind in BPD are proposed.

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