Original Article
The ‘extreme female brain’: increased cognitive empathy as a dimension of psychopathology

https://doi.org/10.1016/j.evolhumbehav.2016.02.003Get rights and content

Abstract

Baron-Cohen's ‛extreme male brain’ theory postulates that autism involves exaggerated male-typical psychology, with reduced empathizing (considered here as social–emotional interest, motivation and abilities) and increased systemizing (non-social, physical-world and rule-based interest, motivation and abilities), in association with its male-biased sex ratio. The concept of an ‘extreme female brain’, involving some combination of increased empathizing and reduced systemizing, and its possible role in psychiatric conditions, has been considerably less well investigated. Female-biased sex ratios have been described in two conditions, depression and borderline personality disorder (BPD), that also show evidence of increases in aspects of empathy in some studies. We evaluated the hypothesis that BPD and depression can be conceptualized in the context of the ‘extreme female brain’ by: (1) describing previous conceptualizations of the extreme female brain model, (2) reviewing evidence of female-biased sex ratios in BPD and depression, (3) conducting meta-analyses of performance on the Reading the Mind in the Eyes test (RMET) among individuals with BPD, clinical or sub-clinical depression, and other psychiatric conditions involving altered social cognition and mood (schizophrenia, bipolar disorder, eating disorders, and autism), in relation to disorder sex ratios, and (4) evaluating previous evidence of increased empathic performance in these, and related, psychiatric conditions, and (5) synthesizing these lines of evidence into models for causes and effects of an ‘extreme female brain’. Our primary empirical results are that RMET performance is enhanced in sub-clinical depression, preserved in borderline personality disorder, and reduced in other disorders (by meta-analyses), and that across disorders, more male-biased patient sex ratios are strongly associated with worse RMET performance of patients relative to controls. Our findings, in conjunction with previous work, suggest that increased cognitive empathizing mediates risk and expression of some psychiatric conditions with evidence of female biases, especially sub-clinical depression and borderline personality disorder, in association with increased attention to social stimuli, higher levels of social and emotional sensitivity, negative emotion biases, and over-developed mentalist thought. These results link evolved human sex differences with psychiatric vulnerabilities and symptoms, and lead to specific suggestions for future work.

Introduction

Evolved sex differences in psychological and biological traits play important roles in the development, causes, and manifestations of many psychiatric conditions (Rutter, Caspi, & Moffitt, 2003). The ‘extreme male brain’ (EMB) theory of autism postulates that autism spectrum conditions reflect extreme manifestations of ‘male-typical’ psychology due in part to high prenatal testosterone (Baron-Cohen, 2002, Baron-Cohen et al., 2005). This theory can help to account for several notable features of autism, including its strongly male-biased sex ratio and reduced performance in measures of empathy and theory of mind (Baron-Cohen et al., 2011). Given the usefulness of the EMB theory in generating testable hypotheses and accounting for patterns in data on autism, it is of interest to investigate the other side of the spectrum: if extreme psychological ‘maleness’ can manifest in autism spectrum traits, what psychological traits and psychiatric conditions might be associated with extreme psychological ‛femaleness’?

Consideration of human psychological sex differences in the context of psychiatric conditions requires addressing two central issues at the outset. First, the ‘extreme male brain’ (EMB) and ‘extreme female brain’ (EFB) in this context have been defined psychologically and seldom involve neurological studies; the EFB and EMB, thus mainly describe psychological profiles that exist at the extreme ends of normal distributions of sexually-dimorphic psychological traits (e.g., Grove, Baillie, Allison, Baron-Cohen, & Hoekstra, 2013). Psychological traits that differ between males and females do so statistically when measured from large samples, meaning that sex differences are small but statistically significant at the population level. Because the distributions of these psychological traits overlap considerably between the sexes, an individual male may exhibit EFB phenotypes, and likewise, an individual female may express EMB traits; however, statistically, an EMB profile is more likely to describe a male and an EFB profile is more likely in a female (Baron-Cohen et al., 2005). Average sex differences are important, however, in that they may result in the extremes of distributions of sex-differential psychological phenotypes exhibiting strong sex biases, depending on the shapes of the distributions.

Second, the extreme development of many normally-distributed traits can mediate the expression of psychiatric conditions, as for personality disorders that explicitly represent maladaptive extremes of psychological personality variation (e.g., Nettle, 2007a, Trull, 2012, Trull and Durrett, 2005, Widiger and Presnall, 2013), and for more-severe psychiatric disorders whose psychological phenotypes grade more or less continuously into those of non-clinical populations (e.g. Constantino, 2011, van Nierop et al., 2012). For psychological and psychiatric phenotypes that are normally distributed as well as sexually dimorphic, extreme developments are thus expected to occur more often within one sex than the other and to contribute to psychological dysfunction.

In this article, we develop and evaluate central aspects of the construct of the ‘extreme female brain’ in relation to psychiatric conditions. We first briefly explain Baron-Cohen's ‘extreme male brain’ model of autism spectrum conditions, in the context of his psychological model of low empathizing in combination with high systemizing and the male-biased sex ratios found in association with autism. Second, we describe previous conceptualizations of the ‘extreme female brain’ construct, and their relationships with empathizing, systemizing, and biased sex ratios, and our model of the EFB as proposed and evaluated here. Third, we evaluate our hypothesis through: (1) review and evaluation of evidence regarding sex ratio biases in BPD and depression, two conditions postulated as reflecting extreme female brain phenotypes that have yet to be analyzed in this context, (2) using meta-analyses to evaluate the prediction that cognitive empathizing ability, as indicated by the Reading the Mind in the Eyes test (RMET) (Baron-Cohen, Wheelwright, Hill, Raste, & Plumb, 2001) is increased or preserved in BPD and clinical or sub-clinical depression, but not in other psychiatric conditions (bipolar disorder, schizophrenia, eating disorders, and autism); and (3) testing for a positive association between higher RMET performance in patients compared to controls, and more female-biased disorder sex ratios, across this set of disorders. Finally, we discuss the implications and limitations of our results, and make suggestions for future research.

Section snippets

Empathizing, systemizing, and the extreme male brain

A powerful framework for understanding patterns of psychological sex differences is the empathizing–systemizing (E–S) theory, which suggests that humans have evolved two parallel and complementary cognitive-affective systems (Baron-Cohen, 2002, Baron-Cohen et al., 2003, Baron-Cohen and Wheelwright, 2004, Baron-Cohen et al., 2005, Baron-Cohen et al., 2011, Chakrabarti and Baron-Cohen, 2006). By this theory, ‘empathizing’ involves the motivation and skills required to understand and interact

Previous accounts of the ‘extreme female brain’

Baron-Cohen, 2002, Baron-Cohen, 2012 suggested that increased empathizing drive and abilities need not negatively impact social functioning and engender psychiatric illness, and that low systemizing would be unlikely to cause impairment in psychological functioning. However, in these articles he did not explicitly consider extreme high levels of empathizing or combinations of high empathizing with low systemizing in the context of psychopathologies. A suite of researchers (Abu-Akel, 1999,

Sex ratios in borderline personality disorder and depression

Baron-Cohen's extreme male brain theory for autism was inspired, in part, by the strong male biases found among individuals with autism spectrum disorders, which suggest that males are predisposed to autism as a consequence of how they differ, psychologically, from females (Baron-Cohen et al., 2011). In parallel to this reasoning, an extreme female brain theory for psychiatric conditions should, as noted above, apply most directly to disorders that show female biases in their prevalence.

Widiger

Borderline personality disorder, depression, and the extreme female brain

The findings described above for female biases in depression and BPD suggest that sufficient evidence exists to merit focused investigation of the degree to which risk and expression of these psychiatric conditions may be modulated, in part, by high empathizing or some combination of high empathizing with low systemizing. Here, we focus primarily on the hypothesis that the causes of depression (clinical, sub-clinical or both) and BPD are mediated by the empathizing dimension of an EFB cognitive

Reading the Mind in the Eyes in BPD, depression and other disorders

To conduct meta-analyses of RMET performance among different psychiatric conditions, we accessed Web of Science to compile a list of all publications that cited Baron-Cohen et al.’s (2001) article on the widely-used version of the RMET. Inclusion criteria comprised: (1) use of an adult version of the RMET as developed by Baron-Cohen et al. (2001); (2) application to patient and control populations, or non-clinical populations scored for psychiatric phenotypes, for all psychiatric conditions for

Causes of enhanced or preserved mentalizing in BPD, sub-clinical depression and other conditions

In autism, a combination of enhanced perceptual, visual–spatial abilities, and systemizing, with reduced empathizing, is considered to jointly contribute to dysfunction in social interactions. By contrast, this review, and the previous work described above, have provided evidence that BPD and sub-clinical depression are associated, to some degree, with an apparently paradoxical combination of enhanced (or preserved) cognitive empathizing abilities and deficits in interpersonal social

Conclusions, limitations and implications

We have provided here the first comprehensive theoretical and empirical framework for analysis and understanding of the EFB. Our main conclusion is that a notable body of evidence supports the hypothesis that the EFB model may be applicable to sub-clinical depression and BPD in particular, and psychotic-affective conditions more generally, just as the EMB model is applicable to autism spectrum conditions. The primary lines of evidence relevant to this inference include: (1) enhanced or

Supplementary Materials

The following are the supplementary data related to this article.

Supplementary File 1.

Acknowledgments

We are grateful to K. Harkness, M.-C. Lai, K. Levy, M. Lombardo, M. Sabbagh, S. Unoka and L. Scott for providing us with raw data for RMET effect size calculations, to Silven Read for technical help, to M. del Giudice and three anonymous reviewers for helpful comments, and to NSERC and the Academy of Finland for financial support.

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