Attachment and its vicissitudes in borderline personality disorder

This article reviews the recent literature on attachment and attachment-related constructs in borderline personality disorder, with attention given to how recent findings in this area may inform understanding of the mechanisms underlying the etiology, maintenance, and treatment of the disorder. Most findings on this topic have stemmed from three major areas of research, each of which is reviewed in this article: 1) developmental psychopathology studies; 2) experimental psychopathology studies, particularly those using a neuroscience approach; and 3) treatment studies that have examined variables relevant to attachment. Overall, these findings suggest that attachment and related constructs may factor greatly into the underlying psychopathology of borderline personality disorder and may significantly impact the process and outcome of psychotherapy for the disorder. These findings are discussed as they relate to existing theories and ongoing debates in the field, and the implications for future research and clinical practice are highlighted.

Defensive projection, superimposed on simplistic object relations, erodes patient-provider relationships in high-risk pregnancy: an empirical investigation

In an attempt to illustrate the relevance of psychoanalytic theory and research to behavior medicine, an empirical investigation was conducted of females treated at a high-risk pregnancy specialty clinic (N = 58). Drawing from psychoanalytic object relations theory, it was hypothesized and confirmed that use of projection as a defense mechanism during pregnancy, superimposed on simplistic object relations, predicted an erosion of patient-provider relationships during the pregnancy/postdelivery period. Findings are interpreted through the perspective of mentalization, pertaining to individuals' ability to understand the mental states of self and others, specifically under significant stress. Implications for psychoanalytically oriented assessment and treatment, and for the rift between psychoanalysis and research, are discussed.

Integrating theory-driven and empirically-derived models of personality development and psychopathology: a proposal for DSM V

Although there is growing consensus that the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) should replace the categorical view of mental disorders with a dimensional approach rooted in personality theory, no consensus has emerged about the dimensions that should be the basis of the new classification system. Moreover, recent attempts to bridge the gap between psychiatric nosology and personality theories have primarily relied on empirically-derived dimensional personality models. While this focus on empirically-derived personality theories may result in a psychometrically valid classification system, it may create a classification system that lacks theoretical and empirical comprehensiveness and has limited clinical utility. In this paper, we first argue that research findings increasingly suggest that an integration of theory-driven and empirically-derived models of personality development is not only possible, but also has the potential to provide a more comprehensive and clinically-relevant approach to classification and diagnosis than either approach alone. Next, we propose a comprehensive model of personality development and psychopathology based on an integration of contemporary theory-driven and empirically-derived models of personality. Finally, we outline the implications of this approach for the future development of DSM, and especially its potential for developing research that addresses the interactions between psychosocial and neurobiological processes implicated in personality development and psychopathology.

Process and outcome in psychodynamic hospitalization-based treatment for patients with a personality disorder

This study examined the relationship between the psychotherapeutic process and outcome in 44 patients who completed hospitalization-based psychodynamic treatment for personality disorders. Using self-report and interview ratings, outcome was assessed in terms of symptoms and personality functioning, and the psychotherapeutic process in terms of self and object relations, felt safety, and reflective functioning. Symptom and process measures were administered at intake, every 3 months during treatment, and at 3 and 12 months follow-up. Personality measures were collected at intake, the end of treatment, and at 3 and 12 months follow-up. Using Piecewise Linear Growth Curve Analysis results showed improvement in symptoms, personality functioning, self and object relations and felt safety, but not in reflective functioning. Linear changes in self and object representation and felt safety, but not in reflective functioning, predicted improvement in outcome.

A pathway to therapeutic change: changes in self-representation in the treatment of adolescents and young adults

Processes that lead to normal development of the representations of self and others are also central to understanding processes of therapeutic change. In long-term, intensive, psychodynamically oriented, inpatient treatment of seriously disturbed, treatment-resistant adolescents and young adults, we found that changes in the level of differentiation-relatedness in patients' self-representation were primarily associated with changes in the level of differentiation-relatedness of their description of their therapist. A best-fit model indicated that change in the patient's description of the therapist and of a self-designated significant other outside the family added significantly to the explained variance predicting change in self-representation. Exploratory structural equation modeling also suggested that patients' growing recognition of the therapeutic relationship (measured by a more mature representation of the therapist) is associated with changes in the patients' overall level of clinical functioning. These results add further support to the importance of the therapeutic relationship in building more differentiated and integrated representations of self and of significant others.

Mother and self-representations: investigating associations with symptomatic behavior and academic competence in middle childhood

This article reports two studies examining the content and structural aspects of maternal and self-representations in middle childhood in two prospective studies of 9 to 11-year-old children, their stability over time and interrelations, and their contribution to symptomatology and academic functioning. In Study 1 (N=169), content and structural dimensions of participants' open-ended narratives of self and mother were assessed, and their factor structure was replicated across two consecutive measurement waves carried out a year apart. In Study 2 (N=137), using an independent sample, the authors investigated the associations of self- and maternal representations with teachers' subsequent reports of children's internalizing and externalizing symptomatology and academic competence. It was assumed that dimensions of self-representations played a mediating role in the prediction of children's symptomatology and competence by their maternal representations. Results corroborated the existence of interdependent but distinct representations of self and mother in middle childhood, as well as the stability over time of the structural and thematic aspects within each representation. The content of the self- and maternal representations was found to associate with observed symptomatic behavior, while their structure associated with children's academic competence. In addition, results indicated that self-representation content mediates the association of maternal representation content with subsequent symptomatic behavior. Findings are discussed in the light of the differentiation and interdependence of self- and maternal representations in middle childhood.

The role of attachment styles and interpersonal problems in suicide-related behaviors

The relationships among adult attachment styles, interpersonal problems, and categories of suicide-related behaviors (i.e., self-harm, suicide attempts, and their co-occurrence) were examined in a predominantly psychiatric sample (N = 406). Both anxious and avoidant attachment styles were associated with interpersonal problems. In turn, specific interpersonal problems differentially mediated the relations between attachment style and type of suicide-related behaviors. These findings suggest the importance of distinguishing between these groups of behaviors in terms of etiological pathways, maintenance processes, and treatment interventions.

Psychodynamic and cognitive-behavioral approaches of obsessive-compulsive disorder: is it time to work through our ambivalence?

This paper provides an overview of the growing convergence among psychodynamic and cognitive-behavioral approaches of Obsessive-Compulsive Disorder (OCD). From a traditional psychoanalytic point of view, OCD is mainly conceptualized in terms of a constant conflict between feelings of love and hate. More recent psychodynamic theories of OCD, such as the object-relational model, focus on the role of ambivalent mental representations or cognitive-affective schemas of self and others. This notion of mental representations or schemas links psychodynamic formulations to cognitive-behavioral approaches of OCD. Moreover, there is increasing overlap between psychodynamic and cognitive-behavioral models concerning the core dynamics involved in OCD. Implications of this convergence for future research and clinical practice are discussed.

Validity of the Inventory of Interpersonal Problems (IIP-64) for predicting assertiveness in role-play situations

The Inventory of Interpersonal Problems (IIP-64; Horowitz, Alden, Wiggins, & Pincus, 2000) is a self-report measure of maladaptive relationship behavior. Ninety-five adult female participants completed the IIP-64 and then interacted with a same-sex confederate in three diagnostic role plays, designed to evoke assertive responses. After each role play, both the participant and the confederate judged how assertive the participant had been, using two subscales from the Interpersonal Adjective Scales (IAS; Wiggins, 1995). The participants' general self-images, assessed with the IIP-64, were quite congruent with how they judged their own assertiveness in the role plays. But when role-play assertiveness was judged by the confederate, the match with the participants' general self-images was considerably lower. Our results indicate that self-reported interpersonal problems do not converge well with external judgments of interpersonal behavior.

Depressive experiences in inpatients with borderline personality disorder

We investigate the quality of dependent and self-critical depressive experiences in a hospitalized sample of depressed (n = 17), depressed borderline (n = 29), and borderline non-depressed inpatients (n = 10). Subjects were administered structured diagnostic interviews for axis I and axis II along with the Symptom Checklist-90-Revised Depression Scale (SCL-90-R-DS) and the Depressive Experiences Questionnaire (DEQ). As predicted, there were no differences between the three groups in overall level of impairment or severity of depression. Phenomenologically, however, depressive experiences were quite different. Subjects with borderline personality disorder, with and without a diagnosed depressive disorder, scored higher than subjects with depression only on the measure of anaclitic neediness. Further analyses revealed that anaclitic neediness was significantly associated with interpersonal distress, self-destructive behaviors, and impulsivity. Findings suggest the importance of considering phenomenological aspects of depression in borderline pathology.

Executive neurocognition, memory systems, and borderline personality disorder

Borderline Personality Disorder (BPD) is a common, disabling, and burdensome psychiatric condition. It is characterized by turbulent fluctuations of negative emotions and moods, unstable and conflictual interpersonal relationships, an incoherent and often contradictory sense of self, and impulsive, potentially lethal self-injurious behaviors. The neurobehavioral facets of BPD have not been extensively studied. However, clinical theoreticians and researchers have proposed that the symptoms and behaviors of BPD are, in part, associated with disruptions in basic neurocognitive processes. This review summarizes and evaluates research that has investigated the relationship between executive neurocognition, memory systems, and BPD. Three historical phases of research are delineated and reviewed, and the methodological and conceptual challenges this body of investigation highlights are discussed. Laboratory-based assessment of executive neurocognition and memory systems is integral to an interdisciplinary approach to research in BPD. Such an approach holds promise in elucidating the neurobehavioral facets, development, diagnostic boundaries, prevention, and optimal interventions for this debilitating and enigmatic disorder.

Minding the gap between positivism and hermeneutics in psychoanalytic research

Two quite different cultures are to be found within psychoanalysis, one more clinical in orientation, more focused on meaning and interpretation, and relying primarily on the traditional case study method, the other more research-oriented, focused on cause-and-effect relationships, and relying primarily on methods borrowed from the natural and social sciences. The history of this divide is reviewed and arguments, pro and con, about the potential contributions of specific types of empirical investigation are discussed. Increasingly, it seems, criticisms concerning the scientific status of psychoanalysis are being responded to by empirical research. This has contributed to a growing recognition within the scientific community of the credibility of aspects of psychoanalytic theories and of the effectiveness of psychodynamic treatment. However, some segments of the psychoanalytic community are concerned that this increase in the quantity and quality of empirical research on psychoanalytic concepts risks creating an empirical one-sidedness, while other segments are concerned that not engaging in systematic empirical research can lead to intellectual isolation, fragmentation, stagnation, and orthodoxy. To counter this polarizing tendency, a recommendation is made for methodological pluralism. Adopting this stance could contribute to an enriched understanding of the clinical process and to the development of new research methodologies to investigate complex psychodynamic hypotheses, thus bridging the gap between the two psychoanalytic cultures, as well as the gap between research and clinical practice.

The action formulation: A proposed heuristic for clinical case formulation

The authors propose the action formulation (TAF), a heuristic for clinical case formulation. The action formulation relies on the action perspective, which depicts individuals as actively shaping their environment, and is premised upon four guidelines: (a) map the client's social environment, focusing on sources of support, chronic interpersonal difficulties, and negative and positive life events; (b) identify how the clients, in the context of their personalities, psychopathologies, and strengths, actively influence their environment; (c) differentiate between maladaptive, risk-related, interpersonal cycles, and adaptive, protective-based ones; and (d) tailor integrative techniques to short-circuit the former cycles and bolster the latter ones. Links between TAF and emerging issues in clinical assessment are discussed.

The implications of attachment theory and research for understanding borderline personality disorder

Borderline personality disorder (BPD) is a highly prevalent, chronic, and debilitating psychiatric problem characterized by a pattern of chaotic and self-defeating interpersonal relationships, emotional lability, poor impulse control, angry outbursts, frequent suicidality, and self-mutilation. Recently, psychopathology researchers and theorists have begun to understand fundamental aspects of BPD such as unstable, intense interpersonal relationships, feelings of emptiness, bursts of rage, chronic fears of abandonment and intolerance for aloneness, and lack of a stable sense of self as stemming from impairments in the underlying attachment organization. These investigators have noted that the impulsivity, affective lability, and self-damaging actions that are the hallmark of borderline personality occur in an interpersonal context and are often precipitated by real or imagined events in relationships. This article reviews attachment theory and research as a means of providing a developmental psychopathology perspective on BPD. Following a brief review of Bowlby's theory of attachment, and an overview of the evidence with respect to the major claims of attachment theory, I discuss individual differences, the evidence that these differences are rooted in patterns of interaction with caregivers, and how these patterns have important implications for evolving adaptations and development. Following this discussion, I present recent work linking attachment theory and BPD, focusing on the implications for understanding the etiology and treatment of BPD. In conclusion, I address some of the salient issues that point to the direction for future research efforts.

Assessing interpersonal perceptions using the interpersonal grid

Three studies were conducted using the interpersonal grid, a method for assessing perceptions of agentic and communal behavior based on the interpersonal circumplex. The 1st examined consistency across perceivers and convergence between perceiver and the perceived person. The 2nd examined whether responses to the interpersonal grid were sensitive to an experimental manipulation of portrayed agency and communion. The 3rd used the interpersonal grid in an event-contingent recording study. The reliability and validity of the measure were supported by findings demonstrating generalizability across perceivers, generalizability across perceptions of events involving the same person, convergence between perceiver and perceived person, and sensitivity to changes in levels of agency and communion. Applications of the interpersonal grid to clinical practice and research are described.

Changes in representations of a self-designated significant other in long-term intensive inpatient treatment of seriously disturbed adolescents and young adults

Blatt and colleagues (1996) found that severity of psychopathology in seriously disturbed, treatment-resistant, hospitalized adolescents at the beginning of treatment was positively correlated with the degree to which these adolescents were involved in describing their parents. At the end of long-term, intensive, psychodynamically oriented, inpatient treatment of these very troubled adolescents, reduction in the severity of psychopathology correlated significantly with increases in the development of the structural organization of descriptions of mother, father, self, and therapist. These findings suggested that treatment of seriously disturbed, treatment-resistant, adolescent and young adult inpatients seems to involve at least two primary dimensions: 1) disengagement from an intense involvement with parents and 2) development in the structural organization of representations of self and a significant new figure, the therapist. The present study extends these earlier findings by examining changes in the description of a "significant other" that each patient elected to describe at the beginning and the end of treatment. Clinical improvement over the course of treatment was significantly correlated with developmental progression of the significant figure each patient selected to describe (from a grandparent to a close friend) as well as with progression in the developmental organization in which this significant other was described. These findings suggest that treatment of seriously disturbed adolescents and young adults involves a disengagement from an intense involvement with primary caregivers to involvement with others outside the family matrix and the developmental elaboration of the representation of these figures.

The Psychology of Worldviews

A worldview (or “world view”) is a set of assumptions about physical and social reality that may have powerful effects on cognition and behavior. Lacking a comprehensive model or formal theory up to now, the construct has been underused. This article advances theory by addressing these gaps. Worldview is defined. Major approaches to worldview are critically reviewed. Lines of evidence are described regarding worldview as a justifiable construct in psychology. Worldviews are distinguished from schemas. A collated model of a worldview's component dimensions is described. An integrated theory of worldview function is outlined, relating worldview to personality traits, motivation, affect, cognition, behavior, and culture. A worldview research agenda is outlined for personality and social psychology (including positive and peace psychology).

Role of perfectionism and personality disorder features in response to brief treatment for depression

Using data from the Treatment of Depression Collaborative Research Program (TDCRP), the authors compared the role of patients' perfectionism and features of personality disorder (PD) in the outcome of brief treatment for depression. Data were extracted as to patients' intake levels of symptoms; perfectionism; and PD features, measured as continuous variables, as well as their symptoms at termination; their contribution to the therapeutic alliance; and their satisfaction with social relations. Poorer therapeutic outcome was demonstrated for patients with elevated levels of perfectionism and odd-eccentric and depressive PD features. Patients' contribution to therapeutic alliance and satisfaction with social relations were predicted by perfectionism but not by PD features. Results highlight the central role played by patients' personality in the course of brief treatment for depression.

Interpersonal relatedness, self-definition, and their motivational orientation during adolescence: a theoretical and empirical integration

The authors examined a theoretical model linking interpersonal relatedness and self-definition (S.J. Blatt, 1974), autonomous and controlled regulation (E. L. Deci & R. M. Ryan, 1985), and negative and positive life events in adolescence (N = 860). They hypothesized that motivational orientation would mediate the effects of interpersonal relatedness and self-definition on life events. Self-criticism, a maladaptive form of self-definition, predicted less positive events, whereas efficacy, an adaptive form of self-definition, predicted more positive events. These effects were fully mediated by the absence and presence, respectively, of autonomous motivation. Controlled motivation, predicted by self-criticism and maladaptive neediness, did not predict negative events. Results illustrate the centrality of protective, pleasure-related processes in adaptive adolescent development.

Developments in cognitive neuroscience: I. Conflict, compromise, and connectionism

The strength of psychoanalysis has always been its understanding of affect and motivation. Contemporary developments in cognitive neuroscience offer possibilities of integrating sophisticated, experimentally informed models of thought and memory with an understanding of dynamically and clinically meaningful processes. Aspects of contemporary theory and research in cognitive neuroscience are integrated with psychoanalytic theory and technique, particularly theories of conflict and compromise. After a description of evolving models of the mind in cognitive neuroscience, several issues relevant to psychoanalytic theory and practice are addressed. These include the nature of representations, the interaction of cognition and affect, and the mechanisms by which the mind unconsciously forges compromise solutions that best fit multiple cognitive and affective-motivational constraints.

Agency and communion in the structure of parental representations

We administered the revised Assessment of Qualitative and Structural Dimensions of Object Representations (Blatt, Chevron, Quinlan, Schaffer, & Wein, 1992) to 279 male and female undergraduate students and carried out independent principal components analyses of maternal and paternal ratings. Three stable factors, Agency, Communion, and Structure, were found in both sets of ratings. This factor structure differed from that reported by Quinlan, Blatt, Chevron, and Wein (1992). Results found here are consistent with contemporary interpersonal personality theory.

Personality, shame, and the breakdown of social bonds: the voice of quantitative depression research

Scheff's argument (2001), whereby shame and the breakdown of social ties are causality implicated in depression, has potential to inform quantitative research on depression, particularly research focused on determinants of personality vulnerability. In the present article, I relate Scheff's argument to more than two and a half decades of theory and research on the interpersonal nature of depression, and on personality vulnerability to depression. The focus of this review is on the personality theories of Blatt (1974) and Beck (1983), in which an introjective/self-critical/autonomous personality dimension and an anaclitic/dependent/sociotropic personality dimension are each conceptualized as a marker of vulnerability. Reviewing empirical research on these two dimensions, I then point out a certain puzzle emerging from previous findings: The introjective personality dimension appears to confer considerably more vulnerability than the anaclitic personality dimension. An attempt is made to reconcile this puzzle by drawing from Scheff's discussion of shame, as well as from psychosocial research on internal representations of self and others (Blatt, Auerbach, and Levy 1997), and from sociological work on the depressogenic conditions of modernity (Giddens 1991; Seligman 1990).

The development and organization of attachment: implications for psychoanalysis

As a result of John Bowlby's breach with the British Psychoanalytic Society nearly forty years ago, his work, specifically the development of attachment theory, was until recently largely expunged from the psychoanalytic record. However, thanks to developments in both psychoanalytic and attachment theories, a rapprochement has been forged, and a number of scholars are now seeking to integrate these two complementary perspectives. In this paper, the fundamental premises of attachment theory are discussed in light of their relation to psychoanalytic theory. In addition, their application to the clinical situation in both adult and child treatment is discussed.

Own versus Other Standpoints in Self-Regulation: Developmental Antecedents and Functional Consequences

An inner audience is an internal representation of others' values, goals, and standards for the self (other standpoint on self). It contrasts with an internal representation of one's own values, goals, and standards for the self (own standpoint on self). Using self-discrepancy theory ( E. T. Higgins, 1987) as a framework to integrate diverse psychological perspectives on this classic distinction, the authors consider the role of own versus other standpoints in self-regulation. They describe developmental shifts and socialization effects on the self-regulatory strength of own and other standpoints. Evidence that individual differences and sex differences in own versus other standpoints for self-regulation relate to different affective and interpersonal vulnerabilities is reviewed. The concepts of identification and introjection are empirically distinguished in a novel way, and therapeutic implications are discussed.

Introduction to Symposium on Constructing Self with Others

The notion that the self is interpersonally embedded can be found throughout psychology's history. This article presents convergent work from different areas of contemporary psychology that supports and elaborates this notion. M. Baldwin's (1997) experimental work in social cognition demonstrates that self-evaluation varies with the relational schema that is activated. C. R. Snyder and R. L. Higgins (1997) present a social–cognitive personality theory of how people maintain their self theories to satisfy internal and external audiences. S. J. Blatt, J. S. Auerbach, and K. N. Levy's (1997) object-relations theory of the role of mental representations of self and others in psychopathology is supported by research that changes in these representations are associated with improvement in psychotherapy. J. Martin and J. Sugarman's (1997) social–cognitive theory of counseling and psychotherapy as conversational reconstructions of self theories also has research support and raises the issue of whether the self is agentic if socially constructed.