Disorganized Attachment Interactions Among Young Adults With Borderline Personality Disorder, Other Diagnoses, and No Diagnosis

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Trust in Therapeutic Work With Adolescents With and Without Personality Disorders: A Transference-Focused Therapy Perspective

Trust is central to successful therapeutic work with adolescents, but establishing trust can be challenging, especially with adolescents with personality disorders. We present our understanding of trust in working with adolescents with and without personality disorders. We draw on complementary and overlapping perspectives, namely the attachment model, Kernberg's object relations model, and Fonagy's mentalization model. In Kernberg's object relations conceptualization, difficulties in trust experienced by patients with borderline personality disorders result from paranoia associated with splitting and identity diffusion. In Fonagy's mentalization model, epistemic trust is rooted in early experiences of being responded to and understood. We outline how techniques used in transference-focused psychotherapy for adolescents promote the development of the adolescent's capacity to trust by facilitating identity integration, thus reducing paranoia. Finally, we use two clinical case illustrations to demonstrate how trust unfolds in working with adolescents with and without personality disorders.

Mother-child interactions in adolescents with borderline personality disorder traits and the impact of early life maltreatment

BACKGROUND

Early detection and intervention of borderline personality disorder (BPD) in adolescence has become a public health priority. Theoretical models emphasize the role of social interactions and transgenerational mechanisms in the development of the disorder suggesting a closer look at caregiver-child relationships.

METHODS

The current study investigated mother-adolescent interactions and their association with adolescent BPD traits by using a case-control design. Thirty-eight adolescent patients with ≥ 3 BPD traits and their mothers (BPD-G) were investigated in contrast to 35 healthy control dyads (HC-G). Maternal, adolescent and dyadic behavior was coded using the Coding Interactive Behavior Manual (CIB) during two interactions: a fun day planning and a stress paradigm. Additional effects of maternal and/or adolescent early life maltreatment (ELM) on behavior were also explored.

RESULTS

BPD-G displayed a significantly lower quality of maternal, adolescent and dyadic behavior than the HC-G during both interactions. Maternal and adolescent behavior was predicted by BPD traits alone, whilst dyadic behavior was also influenced by general adolescent psychopathology. Exploratory analyses of CIB subscales showed that whilst HC-G increased their reciprocal behavior during stress compared to the fun day planning, BPD-G dyads decreased it. Maternal ELM did not differ between groups or have any effect on behavior. Adolescent ELM was correlated with behavioral outcome variables, but did not explain behavioral outcomes above and beyond the effect of clinical status.

DISCUSSION/CONCLUSION

Our data suggest a stronger focus on parent-child interactions in BPD-specific therapies to enhance long-term treatment outcomes in adolescent BPD patients. Further research employing study designs that allow the analyses of bidirectional transactions (e.g. longitudinal design, behavioral microcoding) is needed.

Adolescent borderline personality traits and dyadic behavior shape mother-adolescent cortisol synchrony

BACKGROUND

Associations between parent and child cortisol levels ("cortisol synchrony") are often reported and positive synchrony may mark dyadic regulation on a physiological level. Although dyadic behavior during interaction and adolescent borderline personality disorder (BPD) traits are linked with individual and dyadic regulatory capacities, little is known about how both factors influence parent-adolescent cortisol synchrony. We hypothesized that cortisol synchrony would differ depending on behavioral synchrony, i.e., smooth reciprocal dyadic interaction patterns, adolescent BPD traits, and their interactions.

METHODS

Multilevel state-trait modeling was implemented to investigate associations between concurrent mother-adolescent state cortisol and mother-adolescent average cortisol levels in a community sample of 76 mother-adolescent dyads. Three saliva samples were collected across interaction paradigms. Behavioral synchrony was observed, and adolescent BPD traits were evaluated using clinical interviews.

RESULTS

First, behavioral synchrony and absence of BPD traits were linked with positive associations between adolescent and maternal state cortisol (positive synchrony), BPD traits with negative associations (negative synchrony). When interaction effects were examined, results were more nuanced. In low-risk dyads (higher behavioral synchrony, no BPD traits) asynchrony was found. When risk (BPD traits) and resource (higher behavioral synchrony) were combined, synchrony was positive. Lastly, in high-risk dyads (lower behavioral synchrony, adolescent BPD traits), negative synchrony was observed. Average adolescent and maternal cortisol levels were consistently positively associated in dyads with higher risk.

CONCLUSIONS

Positive dyadic interaction patterns are associated with positive state cortisol synchrony in mother-adolescent dyads and could buffer the effect of BPD traits, possibly supporting the process of physiological regulation.

Attachment-based parent–adolescent interaction linked to visual attention and autonomic arousal to distress and comfort stimuli

In infancy and in the early years of life, emotion regulation and attachment relationships with parents are tightly intertwined. However, whether this link persists into adolescence has not yet been established and requires exploration. This pilot study utilizes an experimental design to assess the patterns of parent–adolescent interactions that are hypothesised to be related to two specific aspects of adolescents’ emotion regulation, namely: visual attention and autonomic arousal to distress and comfort stimuli. Two innovative and ecologically valid methodologies were utilized to assess (a) patterns of attachment-based parent–adolescent interactions among 39 adolescent–parent dyads from the general population, using the Goal-corrected Partnership in Adolescence Coding System (Lyons-Ruth et al. Goal corrected partnership in adolescence coding system (GPACS), 2005) applied to a conflict discussion task; (b) the two aspects of adolescent emotion regulation were assessed with the Visual/Autonomic Regulation of Emotions Assessment (VAREA) (Vulliez-Coady et al. Visual/Autonomic Regulation of Emotions Assessment, VAREA) paradigm, an attachment-related, emotionally arousing experimental procedure, using a distress-then-comfort paradigm, in conjunction to an eye-tracker synchronized with a physiological device that measured gaze and skin conductance response, (SCR), or emotional reactivity. In line with research in infancy, as predicted, markers of secure parent–adolescent interaction were linked to higher amplitude of SCR for distress and comfort pictures, and with longer attention to comfort pictures. On the other hand, parental role-confusion was associated with less time spent on comfort pictures by the adolescent. Overall, this pilot study suggests that interventions supporting collaborative communication between adolescents and their parents, as well as working to reduce parental role-confusion, may improve adaptive adolescent emotion regulation as assessed via physiological measures.

Vulnerability of personality disorder during the Covid-19 crises - a multicenter survey of treatment experiences among patients referred to treatment

BACKGROUND

The societal shutdown due to the Covid-19 pandemic involved mental health services for personality disorder (PD) and was introduced from 12 March 2020 in Norway. Rapid implementation of treatment modifications was required for patients typically characterized by insecure attachment and vulnerability to separation.

AIM

To investigate immediate reactions to the shutdown of services; alternative treatment received; and differences related to age in a clinical sample of patients with PD.

DESIGN

A survey performed from June to October 2020 (after the first Covid-19 wave) among 1120 patients from 12 units offering comprehensive group-based PD programs.

RESULTS

The response-rate was 12% (N = 133). Negative feelings of anxiety, sadness, and helplessness were noteworthy immediate reactions, but the dominating attitude was accommodation. Younger patients (<26 years) reported more skepticism and less relief. Modified treatment was mainly telephone therapy. Digital therapy was less available, but was more frequent among younger patients. A minority received digital group therapy. Most patients rated the frequency and quality of modified treatments as satisfactory in the given situation, but also worried about own treatment progress, lack of group therapy, and 47% missed seeing the therapist when having telephone consultations.

CONCLUSION

The survey confirms a radical modification from comprehensive group-based PD programs to telephone consultations, low availability of digital consultations and group treatments. Taking a short-term, first wave perspective, the survey indicates a noteworthy capacity among poorly functioning patients for accommodating to a clearly challenging situation, as well as considerable concern about treatment progress.

An Exploratory Study on Resting-State Functional Connectivity in Individuals with Disorganized Attachment: Evidence for Key Regions in Amygdala and Hippocampus

Studies comparing organized (O) and unresolved/disorganized (UD) attachment have consistently shown structural and functional brain abnormalities, although whether and how attachment patterns may affect resting state functional connectivity (RSFC) is still little characterized. Here, we investigated RSFC of temporal and limbic regions of interest for UD attachment. Participants’ attachment was classified via the Adult Attachment Interview, and all participants underwent clinical assessment. Functional magnetic resonance imaging data were collected from 11 UD individuals and seven matched O participants during rest. A seed-to-voxel analysis was performed, including the anterior and the posterior cingulate cortex, the bilateral insula, amygdala and hippocampus as seed regions. No group differences in the clinical scales emerged. Compared to O, the UD group showed lower RSFC between the left amygdala and the left cerebellum (lobules VIII), and lower functional coupling between the right hippocampus and the posterior portion of the right middle temporal gyrus. Moreover, UD participants showed higher RSFC between the right amygdala and the anterior cingulate cortex. Our findings suggest RSFC alterations in regions associated with encoding of salient events, emotion processing, memories retrieval and self-referential processing in UD participants, highlighting the potential role of attachment experiences in shaping brain abnormalities also in non-clinical UD individuals.

Complex PTSD and borderline personality disorder

BACKGROUND

This article builds on a previous review (Ford and Courtois, Borderline Personal Disord Emot Dysregul 1:9, 2014) which concluded that complex posttraumatic stress disorder (cPTSD) could not be conceptualized as a sub-type of either PTSD or BPD. Recent research is reviewed that extends and clarifies the still nascent understanding of the relationship between cPTSD and BPD.

MAIN BODY

The circumscribed formulation of adult cPTSD that has been developed, validated, and included in the 11th Edition of the International Classification of Diseases has spurred research aimed at differentiating cPTSD and BPD both descriptively and empirically. A newly validated Developmental Trauma Disorder (DTD) syndrome for children and adolescents provides a basis for systematic research on the developmental course and origins of adult cPTSD and BPD. This review summarizes recent empirical findings regarding BPD, PTSD, and cPTSD in terms of: (1) prevalence and comorbidity; (2) clinical phenomenology; (3) traumatic antecedents; (4) psychobiology; (5) emotion dysregulation; (6) dissociation; and (7) empirically supported approaches to clinical assessment and psychotherapeutic treatment.

CONCLUSION

The evidence suggests that PTSD, cPTSD, and BPD are potentially comorbid but distinct syndromes. A hypothesis is advanced to stimulate scientific research and clinical innovation defining and differentiating the disorders, positing that they may represent a continuum paralleling the classic conceptualization of the stress response, with dissociation potentially involved in each disorder.

Emerging child competencies and personality pathology: toward a Developmental Cascade model of BPD

The guiding principle of this synthesis is to organize research on predictors of BPD features within a developmentally specific framework (e.g. infancy, preschool, middle childhood, adolescence). In addition, studies are prioritized that have longitudinal and observational components. On the basis of current literature, a Developmental Cascade Model of BPD is offered in which specific difficulties during one developmental period contribute to specific difficulties in a succeeding period, resulting in increasingly broad areas of dysregulation over time. Furthermore, to address specificity, we contrast trajectories toward BPD with trajectories toward antisocial behavior, noting shared and divergent predictors. The review highlights the importance of locating research findings in relation to the competencies and challenges of particular developmental periods when modelling developmental trajectories toward BPD.

Emerging child competencies and personality pathology: toward a Developmental Cascade model of BPD

The guiding principle of this synthesis is to organize research on predictors of BPD features within a developmentally specific framework (e.g. infancy, preschool, middle childhood, adolescence). In addition, studies are prioritized that have longitudinal and observational components. On the basis of current literature, a Developmental Cascade Model of BPD is offered in which specific difficulties during one developmental period contribute to specific difficulties in a succeeding period, resulting in increasingly broad areas of dysregulation over time. Furthermore, to address specificity, we contrast trajectories toward BPD with trajectories toward antisocial behavior, noting shared and divergent predictors. The review highlights the importance of locating research findings in relation to the competencies and challenges of particular developmental periods when modelling developmental trajectories toward BPD.

Disorganized Attachment pattern affects the perception of Affective Touch

Touch, such as affective caress, can be interpreted as being pleasant. The emotional valence that is assigned to touch is related to certain bottom-up factors, such as the optimal activation of C-tactile (CT) afferents. Tactile processing with a hedonic or emotional component has been defined as affective touch—a component that CT fibers are likely to convey. Tactile deficiencies are frequent in the psychiatric population but also in healthy people with disorganized attachment; accordingly, it is likely that affective difficulties in adults with disorganized attachment are reflected in altered perception of affective touch. To test this hypothesis, we combined methods from clinical psychology, psychophysics, and neuroimaging. We found that people with a history of traumatic parental bonds and a disorganized attachment pattern perceive a “caress-like” stimulus as being unpleasant, whereas participants with organized attachment consider the same tactile stimulation to be pleasant. Further, unlike in organized adults, the responses of disorganized adults to CT and non-CT stimulation activated limbic and paralimbic structures in a fight-or-flight manner, suggesting that early experiences with parental deficiencies shape the physiological responses of peripheral CT fibers and central nervous networks.

Aspects of Parent-Child Interaction from Infancy to Late Adolescence Are Associated with Severity of Childhood Maltreatment through Age 18

Childhood maltreatment (CM) is a pervasive public health problem worldwide, with negative health consequences across the lifespan. Despite these adverse outcomes, identifying children who are being maltreated remains a challenge. Thus, there is a need to identify reliably observable features of parent-child interaction that indicate risk for CM and that can instigate strategically targeted family supports. The aim of this longitudinal study was to assess multiple aspects of observed mother-child interaction from infancy to late adolescence as risk indicators of the overall severity of CM by age 18. Mother-child dyads were assessed in infancy (N = 56), at age 7 years (N = 56), and at age 19 years (N = 56/110). Severity of CM through age 18 was indexed by combined prospective and retrospective assessments. Interactions associated with severity of CM by age 18 included maternal hostility in infancy, maternal withdrawal in infancy and middle childhood, child disorganized attachment behavior in middle childhood and late adolescence, as well as hostile and role-confused interactions in late adolescence. This study identifies new indices of maternal and child behavior as important risk indicators for the severity of CM. These indices could be used to improve early identification and tailor preventive interventions for families at risk for CM.

Disentangle the neural correlates of attachment style in healthy individuals

Since its development and theorisation in the 60s, attachment theory has greatly influenced both clinical and developmental psychology suggesting the existence of complex dynamics based on the relationship between an infant and its caregiver, that affects personality traits and interpersonal relationships in adulthood. Many studies have been conducted to explore the association between attachment styles and psychosocial functioning and mental health. By contrast, only a few studies have investigated the neurobiological underpinnings of attachment style, showing mixed results. Therefore, in this review, we described current evidence from structural and functional imaging studies with the final aim to disentangle the neural correlates of attachment style in healthy individuals. Overall, different attachment styles have been correlated with volumetric alterations mainly in the cingulate cortex, amygdala, hippocampus and anterior temporal pole. Consistently, functional imaging studies suggested patterns of activations in fronto-striatal-limbic circuits during the processing of social and attachment-related stimuli. Further studies are needed to clarify the neurobiological signature of attachment style, possibly taking into consideration a wide range of demographic, psychosocial and clinical factors that may mediate the associations between the style of attachment and brain systems (e.g., gender, personality traits, psychosocial functioning, early-life experience).