A controlled study of Hostile-Helpless states of mind among borderline and dysthymic women

Association between childhood maltreatment and attachment disorganization in young adulthood: The protective role of early mother-child interactions

BACKGROUND

Individuals who experience chronic relational trauma within the parent-child relationship are at risk of developing disorganized representations of attachment relationships in the form of Hostile-Helpless (HH) states of mind. While this association is well recognized theoretically, few studies to date have empirically tested predictors of HH states of mind.

OBJECTIVE

The purpose of this study was to examine whether retrospective self-reports of maltreatment and the quality of mother-child affective communication assessed in childhood predict HH states of mind in young adulthood.

METHODS

The sample was composed of 66 young adults from a low-income community sample, who had been taking part in a longitudinal project since they were preschoolers.

RESULTS

Results indicate that childhood maltreatment experiences significantly predict HH states of mind and that the quality of mother-child affective communication serves a protective role in the association between childhood maltreatment severity and adult attachment disorganization.

CONCLUSION

This study is one of the first to prospectively examine how the quality of mother-child affective communication in childhood relates to attachment disorganization in young adulthood. Our results highlight the importance of providing support to families in which the child is at risk of experiencing relational trauma, with a particular focus on improving the quality of parent-child interactions.

History of abuse and adolescent hostile-helpless attachment: The mediating role of mother-adolescent punitive interactions

BACKGROUND

Hostile-Helpless (HH) state of mind is a form of disorganised attachment that is strongly associated with prior experiences of abuse. However, how abuse experiences contribute toward HH states of mind in late adolescence is unknown. Punitive control in adolescent-mother dyads has been implicated in the development of HH states of mind and adolescent sex/gender may influence how punitive interactions contribute to HH mind states.

OBJECTIVE

The present study aimed to explore how adolescent sex/gender and punitive control within adolescent-mother dyads are related to the links between HH states of mind and childhood abuse.

PARTICIPANTS AND SETTING

A sample of 109 low-moderate income late adolescents (aged 18-23 years, 65 females, 44 males) and their mothers were assessed in a conflict-resolution paradigm.

METHODS

Recordings of the interactions were coded using the Goal-Corrected Partnership in Adolescence Coding System for different aspects of attachment-based interactions including punitive control. Late-adolescent HH states of mind features were coded from Adult Attachment Interviews (AAI) and experiences of abuse were coded from adolescent self-reports and the AAI.

RESULTS

Moderated mediation analysis revealed a significant indirect pathway from abuse to HH states of mind through punitive control in late adolescent females (B = 0.06, SE_Boot = 0.04, 95 % CI_Boot 0.01, 0.15), but not males (B = -0.02, SE_Boot = 0.02, 95 % CI_Boot - 0.07, 0.02).

CONCLUSIONS

The results indicate that there are sex/gender-specific pathways to developing HH states of mind. Hostile behavior within mother-daughter dyads therefore may play an important role in linking abuse experiences and contradictory attachment representations in late adolescent females.

[Intrusive touch of borderline parenting and risk of disorganized attachment of children]

The development of attachment in toddlers is linked to the quality of their early interactions with their mother and father. The impact of interactive dysfunctions, in relation to different parental circumstances, constitutes an important risk for the development of disorganized attachment. Although this aspect is fairly well known, few studies have been done on the children of people with borderline personality disorder.

Transmission of parental childhood trauma to child behavior problems: Parental Hostile/Helpless state of mind as a moderator

BACKGROUND

Little attention has been given to intergenerational transmission of risk, mainly whether caregivers' history of childhood maltreatment is linked to behavioral symptoms in their children and which protective/risk factors are involved in this transmission process.

OBJECTIVE

This study examined if parental Hostile/Helpless (H/H) state of mind with respect to attachment moderated the association between parental childhood trauma and behavior problems in maltreated children.

PARTICIPANTS AND SETTING

The sample included 61 parents and their children victims or at very high risk of maltreatment, aged between 1 and 6 years old.

METHOD

Parents retrospectively reported their childhood trauma and completed a measure of their children's behavior problems. Independent observers assessed H/H attachment representations.

RESULTS

Among parents with H/H states of mind, more severe traumatic childhood experiences were associated with more externalizing and internalizing behavior problems in their children. Among non-H/H parents, associations between parental childhood trauma and child behavior problems were not significant.

CONCLUSIONS

In the context of trauma, this study suggests that the absence of a H/H state of mind in parents (i.e., the presence of an organized attachment state of mind) is a protective factor for child adjustment. H/H mental representations of self and attachment experiences as targets of intervention for parents with histories of maltreatment may help reduce the transmission of risk in maltreating families.

Hostile-helpless states of mind: A scoping review of risk factors, correlates, and consequences

Chronic relational trauma can lead to the formation of pervasively unintegrated attachment representations in adulthood, referred to as Hostile-Helpless (HH) states of mind. Individuals with this type of attachment disorganization evidence conflicting evaluations of caregivers and have difficulty reflecting on their traumatic childhood experiences. This scoping review is the first to systematically integrate the results of all empirical studies on HH states of mind in an effort to highlight the scientific and clinical contributions of the concept and guide future research. Following Arksey and O'Malley's (2005) Methodological Framework, cross-reference keywords were searched in three databases (PsycArticles, Psychology and Behavioral Sciences Collection, ProQuest). In total, 19 studies met inclusion criteria and were included in the synthesis. Results suggest that prevalence rates of HH states of mind increase as a function of adults' psychosocial risk status. Findings also reveal that the long-term consequences of early trauma are greater in the presence of a HH state of mind, whereas the absence of a HH state of mind acts as a protective factor against the intergenerational transmission of maladaptation. Finally, results support the discriminant validity of the HH classification against other forms of attachment disorganization in adulthood. Research gaps and future research directions are discussed.

Specific Pathways From Adverse Experiences to BPD in Adolescence: A Criteria-Based Approach of Trauma

Within the European Research Network on BPD (EURNET-BPD; n = 85 BPD adolescents, n = 84 healthy controls, aged 13-19), this study explored the combination of three types of adversity-maltreatment, stressful life events (early separation from parents, parental suicide attempt, parental chronic disease) and parental bonding-as predictors of BPD, on a criteria-based approach. Results indicated that cumulative traumatic experiences largely characterize borderline adolescent's history; and, in the multivariate regression models, all adversity experiences were likely to contribute to BPD symptoms. The role of emotional abuse, parental suicide attempt, and a decrease in paternal level of care were particularly prominent. Moreover, adversities combinations were different for each criterion, suggesting that specific sets of traumatic experiences are leading to BPD. These findings argue for a further criteria-based exploration of trauma in borderline patients, as well as a more accurate and efficient prevention.

Growing points in attachment disorganization: looking back to advance forward

In this special issue paper we reflect on the next generation of attachment research with a focus on disorganization, a central but still poorly understood topic in this area. We suggest that progress will be facilitated by a return to attachment theory's evolutionary roots, and to the emphasis on biological function that inspired Bowlby's original thinking. Increased interdisciplinary cross-fertilization and collaborations would enable novel and generative research on some of the long-standing questions surrounding attachment disorganization. Accordingly, we present an agenda for future research that encompasses contributions of modern ethology and neurobiology, novel hypotheses based on the concept of adaptive decanalization, connections with neurodevelopmental vulnerability and risk for mental disorders such as schizophrenia, and the possibility of sex differences in the behavioral manifestations of attachment disorganization. We believe that these avenues of theory and research offer exciting potential for innovative work in attachment disorganization in the years ahead.

The borderline interpersonal-affective systems (BIAS) model: Extending understanding of the interpersonal context of borderline personality disorder

Prominent explanatory models for borderline personality disorder (BPD) are intrapersonal in nature and hold that it is an emotional disorder. However, the empirical support for emotional models of BPD is mixed. Refinements to BPD explanatory models are needed to increase the precision with which BPD can be understood and treated. Drawing on existing theoretical and empirical research in BPD, this manuscript presents the Borderline Interpersonal-Affective Systems (BIAS) model. The BIAS model purports that harmful early life relationships and subsequent conflictual relationships lead individuals with BPD to develop a sensitivity to interpersonal threat in the form of attentional and appraisal biases. Individuals with BPD are posited to 1) experience heightened emotional reactivity specifically to perceived interpersonal threat and 2) engage in destructive behaviors both to regulate increasing emotion and to meet interpersonal needs. We review the empirical support for each component of the BIAS model, along with the role of the cognitions, emotions, and behaviors of significant others in influencing BIAS model processes in individuals with BPD over time. The BIAS model highlights a novel way of understanding and integrating interpersonal and emotional components of the disorder. Key directives for future research and clinical implications are discussed.

Evaluation of early relational disturbance in high-risk populations: Borderline personality disorder features, maternal mental state, and observed interaction

Despite the longstanding theoretical association in the attachment literature between maternal trauma history and disturbances in the mother-infant interaction, few studies have investigated mechanisms of transmission of traumatogenic relational patterns in high-risk mother-infant dyads. This study investigated interrelationships among maternal trauma history, distorted maternal representations (DMRs, i.e. disturbed thoughts and feelings about the infant and self-as-parent), maternal mentalisation (i.e. capacity to conceive of self and other's intentions in terms of mental states including thoughts, feelings, and desires), and quality of interaction in a clinical sample of mothers with Borderline Personality Disorder (BPD) features and their infants (N = 61). Measures used included the Childhood Trauma Questionnaire, Parent Development Interview, Mother-Infant Relationship Scale, Borderline Symptom Checklist-23, and the Emotional Availability Scales. The results indicated BPD features mediated the relationship between maternal trauma history and DMRs predicting disturbance in interaction. In addition, analyses showed that maternal mentalisation had a buffering effect between DMRs and maternal non-hostility and yet the severity of BPD features moderated the relationship between mentalisation and DMRs. The findings suggest postpartum borderline pathology may adversely impact the experience of being a parent for women with a relational trauma history including deficits in mentalisation (i.e. hypermentalising) and disturbances in the mother-infant interaction. Implications for research and clinical practice are discussed.

Childhood abuse and neglect experiences, Hostile-Helpless attachment, and reflective functioning in mentally ill filicidal mothers

The present study represents the first empirical investigation of the mechanisms - a Hostile-Helpless (HH) attachment and reflective functioning (RF) - through which childhood abuse and neglect (CA&N) experiences may impact a mother's likelihood to commit filicide. The sample was comprised of 46 mentally ill mothers. Differences in attachment-derived risk variables between filicidal mothers (FM) and non-filicidal mothers (NFM) were also examined. FM (n = 23) reported lower RF, higher HH attachment, and a more severe history of CA&N, compared to NFM (n = 23), but did not differ on the severity of childhood experiences of loss of and/or separation from attachment figures. Bayesian analysis indicated that the mediated effect of more severe CA&N on the likelihood of committing filicide through higher HH attachment was significantly amplified by lower RF. A developmental interpretation of filicide is proposed and clinical implications for prevention and attachment-based interventions with at-risk mother-child dyads are discussed.

Narcissistic and Borderline Personality Disorders: Relationship With Oxidative Stress

The authors hypothesized that personality disorders characterized by interpersonal hypersensitivity would be associated with an elevated concentration of 8-hydroxy-2'-deoxyguanosine (8-OH-DG), the oxidized form of guanine, and a biomarker of oxidative stress burden. One hundred ninety-five male and female adults underwent semistructured diagnostic interviews, completed questionnaire measures of social cognition and emotional attribution, and had blood drawn for determination of plasma 8-OH-DG. A hierarchical linear regression model revealed that narcissistic and borderline personality disorders predicted 8-OH-DG level independently of the effects of age, gender, recent alcohol and cigarette use, current major depression, and posttraumatic stress disorder. In all subjects, 8-OH-DG level was also correlated with the number of borderline personality disorder symptoms present. Narcissistic and borderline personality disorders predicted oxidative stress burden independently of potentially confounding factors.

Borderline Personality Disorder in Adolescence as a Generalization of Disorganized Attachment

Several researchers point to disorganized attachment as a core feature of borderline personality disorder (BPD). However, recent studies suggest that specific internal working models (IWMs) of each parent combine to account for child outcomes and that a secure relationship with one parent can protect against the deleterious effects of an insecure relationship with the other parent. It was thus hypothesized that adolescents with BPD are more likely to be disorganized with both their parents, whereas non-clinical controls are more secure with at least one of their caregivers. Thirty-six adolescents with BPD and 30 control participants (aged 13-19) were included. Psychiatrist diagnosis was verified with the Structured Interview for DSM-IV Personality Disorders (SIDP-IV) and comorbidity was assessed using the Kiddie-SADS. Reported trauma was assessed with the Childhood Trauma Questionnaire (CTQ). Attachment IWMs of each parent were assessed with the Attachment Multiple Model Interview (AMMI), which enables separate coding for each attachment figure and in which disorganization is conceptualized as conflicting attachment strategies within a specific relationship. Results of a logistic regression analysis suggested that beyond insecure attachment, being disorganized not just with one but with both parents is particularly characteristic of adolescents with BPD. Conversely, belonging to the non-clinical group was predicted by higher security scores with the father and lower deactivation with the mother. Although higher levels of childhood abuse or neglect were reported by adolescents with BPD, the retained attachment dimensions predicted group membership over and above reported trauma. These findings have important implications for clinical intervention and highlight the protective role fathers may have.

Emotional availability in mothers with borderline personality disorder and mothers with remitted major depression is differently associated with psychopathology among school-aged children

BACKGROUND

Both, maternal borderline personality disorder (BPD) and maternal major depressive disorder (MDD) are often associated with adverse consequences for children, including increased risk for child behavior problems. Reduced maternal emotional availability might play a critical role in transmitting maternal psychopathology on the child. Our aim was to investigate the association between emotional availability and maternal BPD and MDD in remission (rMDD), and if this interrelatedness mediates the association between maternal mental disorders and child behavior problems.

METHODS

The interaction of 178 mother-child dyads was assessed during a play situation using the Emotional Availability Scales. Children were between 5 and 12 years old. Regression analyses were used to investigate the impact of maternal BPD and maternal rMDD on emotional availability. Ordinary least squares regression analyses using bootstrapping were conducted to investigate the mediating effect of emotional availability on the association between maternal mental disorders and child behavior problems.

RESULTS

Mothers with BPD showed increased hostility during mother-child interaction, whereas history of MDD was associated with reduced sensitivity. Maternal hostility was a mediator between maternal BPD and number of child psychiatric disorders, as well as externalizing and internalizing behavior. Maternal sensitivity mediated the association between maternal rMDD and number of child psychiatric disorders, as well as internalizing child behavior.

CONCLUSIONS

Our data suggest that mothers with BPD show a qualitatively different pattern of emotional availability compared to mothers with rMDD. These patterns might reflect two separate pathways of transgenerational transmission of aspects of maternal mental disorders, where intervention and training programs could start: maternal rMDD impacts on child behavior problems via reduced sensitivity, and maternal BPD via increased hostility, which could both be addressed with specific therapeutic interventions.

Intrinsic and extrinsic motivators of attachment under active inference

This paper addresses the formation of infant attachment types within the context of active inference: a holistic account of action, perception and learning in the brain. We show how the organised forms of attachment (secure, avoidant and ambivalent) might arise in (Bayesian) infants. Specifically, we show that these distinct forms of attachment emerge from a minimisation of free energy-over interoceptive states relating to internal stress levels-when seeking proximity to caregivers who have a varying impact on these interoceptive states. In line with empirical findings in disrupted patterns of affective communication, we then demonstrate how exteroceptive cues (in the form of caregiver-mediated AMBIANCE affective communication errors, ACE) can result in disorganised forms of attachment in infants of caregivers who consistently increase stress when the infant seeks proximity, but can have an organising (towards ambivalence) effect in infants of inconsistent caregivers. In particular, we differentiate disorganised attachment from avoidance in terms of the high epistemic value of proximity seeking behaviours (resulting from the caregiver's misleading exteroceptive cues) that preclude the emergence of coherent and organised behavioural policies. Our work, the first to formulate infant attachment in terms of active inference, makes a new testable prediction with regards to the types of affective communication errors that engender ambivalent attachment.

Parenting and personality disorder: clinical and child protection implications

I review some of the evidence that parental personality disorder represents a risk to child development, in terms of both transmission of genetic vulnerability and the environmental stress of living with a parent who has a personality disorder that negatively affects their parenting capacities. I argue that there are two compelling reasons to impose a duty on mental healthcare providers to offer services for adults with personality disorders that specifically focus on their parenting identity: first, because effective therapies for personality disorder are now available; and second, because there is a strong utilitarian and economic argument for improving parental mental health so as to reduce the economic and psychological burden of their offsprings' future psychiatric morbidity.

A Mother's Borderline Personality Disorder and Her Sensitivity, Autonomy Support, Hostility, Fearful/Disoriented Behavior, and Role Reversal With Her Young Child

There is some evidence that maternal borderline personality disorder (BPD) adversely affects parenting in infancy, resulting in disorganized attachment, which longitudinally predicts BPD symptoms in adulthood. We examined parenting related to disorganized attachment beyond infancy in offspring of mothers with BPD, when parenting becomes a goal-corrected partnership. We observed puzzle solving in a low socioeconomic status (SES) sample of mothers with BPD and their children ages 4-7, n = 36, and normative comparisons, n = 34. Compared with normative mothers and controlling for maternal mood disorders, mothers with BPD were less likely to be sensitive and provide autonomy support, and were more likely to be hostile and display fearful/disoriented behavior and higher levels of parent-child role reversal. We additionally found correlations between parenting and self-reported maternal borderline features. We discuss implications for child development, including possible transmission of BPD from mothers to children via representational models, and developmentally appropriate preventive interventions.

The relations between inadequate parent-child boundaries and borderline personality disorder in adolescence

Borderline Personality Disorder (BPD) is a severe mental illness that onsets in adolescence. Research has demonstrated the central role of parent-child relationships for the development and maintenance of BPD although more research is necessary to clarify the specific dynamics that relate to BPD during adolescence. Based on preliminary research establishing the importance of parent-child boundaries for adolescent BPD, this study sought to evaluate the relations between different forms of inadequate boundaries and BPD in adolescence using a multi-method approach. To that end, 301 adolescents (65.1% female; ages 12-17) inpatients were recruited; parents and adolescents completed questionnaire- and interview-based measures of BPD features in adolescent children and a questionnaire-based measure of parent-child boundaries. Relations were found between parental guilt induction and psychological control with children's BPD features above and beyond relations with psychiatric severity and gender. Relations between parent reports of triangulation (when children are recruited to mediate parental marital conflict) and children's BPD were contingent on the level of children's perceptions of triangulation. Findings confirm previous research suggesting the relevance of inadequate parent-child boundaries to children's BPD features and have important implications for understanding the dynamics in families with adolescents with BPD, representing a relevant treatment target.

Social disadvantage and borderline personality disorder: A study of social networks

Examining differences in social integration, social support, and relationship characteristics in social networks may be critical for understanding the character and costs of the social difficulties experienced of borderline personality disorder (BPD). We conducted an ego-based (self-reported, individual) social network analysis of 142 participants recruited from clinical and community sources. Each participant listed the 30 most significant people (called alters) in their social network, then rated each alter in terms of amount of contact, social support, attachment strength and negative interactions. In addition, measures of social integration were determined using participant's report of the connection between people in their networks. BPD was associated with poorer social support, more frequent negative interactions, and less social integration. Examination of alter-by-BPD interactions indicated that whereas participants with low BPD symptoms had close relationships with people with high centrality within their networks, participants with high BPD symptoms had their closest relationships with people less central to their networks. The results suggest that individuals with BPD are at a social disadvantage: Those with whom they are most closely linked (including romantic partners) are less socially connected (i.e., less central) within their social network. (PsycINFO Database Record

Categorical and dimensional approaches in the evaluation of the relationship between attachment and personality disorders: an empirical study

Although several studies have highlighted the relationship between attachment states of mind and personality disorders, their findings have not been consistent, possibly due to the application of the traditional taxonomic classification model of attachment. A more recently developed dimensional classification of attachment representations, including more specific aspects of trauma-related representations, may have advantages. In this study, we compare specific associations and predictive power of the categorical attachment and dimensional models applied to 230 Adult Attachment Interview transcripts obtained from personality disordered and nonpsychiatric subjects. We also investigate the role that current levels of psychiatric distress may have in the prediction of PD. The results showed that both models predict the presence of PD, with the dimensional approach doing better in discriminating overall diagnosis of PD. However, both models are less helpful in discriminating specific PD diagnostic subtypes. Current psychiatric distress was found to be the most consistent predictor of PD capturing a large share of the variance and obscuring the role played by attachment variables. The results suggest that attachment parameters correlate with the presence of PD alone and have no specific associations with particular PD subtypes when current psychiatric distress is taken into account.

Role Confusion and Disorientation in Young Adult-Parent Interaction Among Individuals With Borderline Symptomatology

Borderline symptoms are thought to emerge from the interaction of temperamental factors and environmental stressors. Both parental invalidation and attachment disorganization have been hypothesized to play an etiological role. However, to date the quality of parent-child interaction has not been observed directly. In this study, 120 young adults were assessed for features of borderline personality disorder on the SCID II, for severity of childhood maltreatment on interview and self-report measures, and for disturbance in parent-child interaction during a videotaped conflict discussion task. Borderline traits, as well as suicidality/self-injury specifically, were associated with more role confusion and more disoriented behavior in interaction with the parent. Among young adults with recurrent suicidality/self-injury, 40% displayed high levels of role confusion compared to 16% of those who were not suicidal. Neither form of disturbed interaction mediated the independent effect of childhood abuse on borderline symptoms. A parent-child transactional model is proposed to account for the findings.

Adult Attachment Interview differentiates adolescents with Childhood Sexual Abuse from those with clinical depression and non-clinical controls

Although attachment representation is considered to be disturbed in traumatized adolescents, it is not known whether this is specific for trauma, as comparative studies with other clinical groups are lacking. Therefore, attachment representation was studied by means of the Adult Attachment Interview in adolescents with Childhood Sexual Abuse (CSA) (N = 21), clinical depression (N = 28) and non-clinical controls (N = 28). Coherence of mind and unresolved loss or trauma, as well as the disorganized attachment classification differentiated the CSA group from the clinical depression group and controls, over and above age, IQ, and psychiatric symptomatology. In the current era of sustained criticism on criteria-based classification, this may well carry substantial clinical relevance. If attachment is a general risk or vulnerability factor underlying specific psychopathology, this may guide diagnostic assessment as well as treatment.

Security and the social mind: attachment and therapeutic communities

Purpose

– The purpose of this paper is to describe some of the basic features of attachment theory, and explore how they relate to the development of the “social mind” and the work of therapeutic communities (TC).

Design/methodology/approach

– The author describes the essentials of attachment theory in humans; and the development of both secure and insecure states of mind. The author will set out how insecure attachment systems are associated with deficits in mentalising processes which are fundamental to the activity of the social mind.

Findings

– The author suggests how attachment to a TC can promote mentalising processes. The author draws on the work of other speakers in the conclusions about how to “grow” secure minds and societies.

Research limitations/implications

– This paper is a brief over view only and does not address attachment process to TC in any depth.

Practical implications

– Attachment theory could help both service users and therapists who work in TCs understand some of the difficulties people have in engaging at the start. Attachment theory also gives a guide to what a “good enough” experience in a TC might look like.

Originality/value

– There is little existing discussion of the application of attachment theory to TCs.

The relationship of psychological trauma and dissociative and posttraumatic stress disorders to nonsuicidal self-injury and suicidality: a review

We reviewed research on the relationship between (a) exposure to psychological trauma and (b) nonsuicidal self-injury (NSSI) and suicidality (suicidal ideation [SI] and suicide attempts [SA]) in individuals with dissociative disorders and posttraumatic stress disorder (PTSD). The review provides a context for the special issue of the Journal of Trauma & Dissociation on these topics. Exposure to childhood sexual abuse is the most consistent traumatic antecedent of self-harm, although traumatic violence in childhood (particularly physical abuse) and adulthood (particularly domestic violence) and exposure to multiple types of traumatic stressors also are associated with NSSI and SI/SA. Dissociative disorders and PTSD are consistently associated with increased NSSI and SA/SI. There is preliminary cross-sectional evidence that dissociation and posttraumatic stress disorders may mediate the relationship between psychological trauma and NSSI and SI/SA. Research on emotion dysregulation as a potential cross-cutting mechanism linking dissociation, PTSD, and self-harm is also reviewed. We conclude with a discussion of implications for clinical practice and future directions for scientific research.

Hostile-Helpless state of mind as further evidence of adult disorganized states of mind in neglecting families

This study aimed to assess disorganized states of mind in a sample of neglecting and at-risk of neglecting mothers using the recently developed Hostile-Helpless (HH) coding system (Lyons-Ruth et al., 2006) for the Adult Attachment Interview (Main & Goldwyn, 1998). The relation between HH states of mind and mothers' childhood traumas was also examined. Participants were 70 neglecting mothers and at-risk of neglecting mothers. Childhood traumas were assessed using the Childhood Trauma Questionnaire. HH states of mind were coded from Adult Attachment Interview transcripts by two reliable coders. Results revealed a high prevalence of disorganized states of mind in this sample. Forty-five mothers were classified HH, representing 64% of the entire sample. Most mothers reported at least one form of childhood trauma, with a mean of 2.9 different forms of trauma. Mothers classified HH reported having been emotionally abused, sexually abused and physically neglected more frequently than non-HH mothers. There was no difference between neglecting and at-risk of neglect mothers on HH states of mind and childhood experiences of trauma. These findings are in line with theorization on maltreating mothers' psychological background and they provide further empirical support to the validation of the HH classification system with at-risk populations.

Three-week inpatient Cognitive Evolutionary Therapy (CET) for patients with personality disorders: evidence of effectiveness in symptoms reduction and improved treatment adherence

OBJECTIVES

The aim of this study was to evaluate the efficacy of Cognitive Evolutionary Therapy (CET) in an intensive short residential treatment of a wide range of severe personality disorders (PDs) that resulted in a reduction of social functioning and significant personal distress.

DESIGN

Each patient was assessed at admission, discharge, and 3 months later in order to determine if there was a reduction in symptoms and an improved adherence to former outpatient programs and to check if patients were undergoing new treatment after discharge.

METHOD

Fifty-one patients participated in this study. The 20-hr weekly program consisted of two individual sessions and various group modules. Outcome measures included: self-reported measures of depression, anxiety, general symptoms, number and duration of inpatient admissions after the programme, and continuation in an outpatient treatment programme.

RESULTS

The results show an overall improvement in general psychopathology after the release and in follow-up sessions, a decrease in the number of further hospital admissions, and an increased level of attendance of outpatient therapy.

CONCLUSIONS

This study shows that intensive short residential treatment is an effective treatment for patients with a wide range of PDs.

Borderline symptoms and suicidality/self-injury in late adolescence: prospectively observed relationship correlates in infancy and childhood

The primary objective was to assess whether prospectively observed quality of parent-child interaction in infancy and middle childhood contributed to the prediction of borderline symptoms and recurrent suicidality/self-injury in late adolescence. Adolescents (mean 19.9 years) from 56 families participating in a longitudinal study since infancy (retention rate 74%) were assessed on the SCID-II for symptoms of borderline personality disorder (BPD), including suicidality/self-injury. Early clinical risk was indexed by clinical referral to parent-infant services. Attachment security and parent-child interaction were assessed from videotape at 18 months and 8 years. Severity of childhood abuse was rated from interview and self-report measures. Maternal withdrawal in infancy was a significant predictor of both borderline symptoms and suicidality/self-injury in late adolescence. Disorganized controlling child behavior at age 8 contributed independently to the prediction of borderline symptoms. The effect of maternal withdrawal was independent of, and additive to, variability explained by severity of childhood abuse. Borderline symptoms and suicidality/self-injury may be preceded developmentally by disturbed interactions as early as 18 months of age. A parent-child transactional model is proposed to account for the findings.

Disorganized behavior in adolescent-parent interaction: relations to attachment state of mind, partner abuse, and psychopathology

Disoriented, punitive, and caregiving/role-confused attachment behaviors are associated with psychopathology in childhood, but have not been assessed in adolescence. A total of 120 low-income late adolescents (aged 18-23 years) and parents were assessed in a conflict-resolution paradigm. Their interactions were coded with the Goal-Corrected Partnership in Adolescence Coding Scales. Confirmatory factor analysis demonstrated that the three disorganized constructs (punitive, caregiving, and disoriented interaction) were best represented as distinct factors and were separable from a fourth factor for collaboration. The four factors were then assessed in relation to measures of attachment disorganization, partner abuse, and psychopathology. Results indicate that forms of disorganized behavior first described in early childhood can also be reliably assessed in adolescence and are associated with maladaptive outcomes across multiple domains.

MATERNAL ROLE CONFUSION: RELATIONS TO MATERNAL ATTACHMENT AND MOTHER-CHILD INTERACTION FROM INFANCY TO ADOLESCENCE

Self-reports of role confusion with the parent in childhood are associated with a variety of adverse outcomes. However, role-confusion has been studied primarily from the point of view of the child. The current study evaluated an instrument for assessing role confusion from maternal interviews rather than from child observations or self-reports in adulthood. Fifty-one mothers participating in a longitudinal study since their own child's infancy were administered the Experiences of Caregiving Interview (C. George & J. Solomon, 1996) when the child was age 20. Interviews were coded using the newly developed Parental Assessment of Role Confusion (PARC; L. Vulliez-Coady & K. Lyons-Ruth, 2009). Maternal PARC scores were related to observational measures of role-confusion in interaction with the child both in infancy and late adolescence. PARC scores also were related to mothers' hostile-helpless states of mind on the Adult Attachment Interview (C. George, N. Kaplan, & M. Main, 1984, 1985, 1986) and to the extent of Unresolved loss, but not Unresolved Trauma. PARC scores also were related to mothers' self-reports of helplessness experienced in the parenting role. Discriminant validity of the PARC was demonstrated in that role confusion on the PARC was not related to hostile or disoriented forms of parent-child interaction. Implications for clinical assessment of role confusion are discussed.

Emotion as Personal Relatedness

In this article, I consider the structure of interpersonal emotional relations. I argue that current cognitive-developmental theory has overestimated the role of conceptual thinking, and underestimated the role of intrinsic social-emotional organization, in the early development of such feelings as jealousy, shame, and concern. I suggest that human forms of social experience are shaped by a process through which one individual identifies with the bodily expressed attitudes of other people, and stress the diversity of self–other relational states. I draw on studies in developmental psychopathology, and specifically research in autism and borderline personality disorder, to illustrate some implications of this viewpoint.

Is self disturbance the core of borderline personality disorder? An outcome study of borderline personality factors

OBJECT

To determine which constellation of clinical features constitutes the core of borderline personality disorder (BPD).

METHOD

The criterion of endurance was used to identify the constellation of features which are most basic, or core, in borderline personality disorder. Two sets of constellations of DSM-III features were tested, each consisting of three groupings. The first set of constellations was constructed according to Clarkin's factor analysis; the second was theoretically derived. Broadly speaking, the three groupings concerned 'self', 'emotional regulation', and 'impulse'. Changes of these constellations were charted over one year in a comparison of the effect of treatment by the Conversational Model (n = 29) with treatment as usual (n = 31). In addition, measures of typical depression (Zung) were scored before and after the treatment period. The changes in the constellations were considered in relation to authoritative opinion.

RESULTS

The changes in the two sets of constellations were similar. In the treatment as usual (TAU) group, 'self' endured unchanged, while 'emotional regulation' and 'impulse' improved. In the Conversational Model cohort, 'self' improved, 'emotional regulation' improved more greatly than the TAU group, while 'impulse' improved but not more than the treatment as usual group. Depression scores were not particularly associated with any grouping.

CONCLUSIONS

A group of features including self/identity disturbance, emptiness and fear of abandonment may be at the core of BPD. Correlations between the three groupings and Zung scores favoured the view that the core affect is not typical depression. Rather, the central state may be 'painful incoherence'. It is suggested that the findings have implications for the refinement and elaboration of treatment methods in borderline personality disorder.

Revising the borderline diagnosis for DSM-V: an alternative proposal

The changes in the borderline personality disorder (BPD) diagnosis proposed by the DSM-V personality disorder work group involve radical changes in format (prototype and dimensions) and descriptive characteristics (traits). Changes of this magnitude will create an unwelcome and potentially harmful discontinuity with the definition that has guided BPD research and the development of disorder-specific therapies. This paper offers an alternative proposal that was developed in collaboration with clinical and research leaders. It includes modification of existing criteria, use of a diagnostic algorithm based on phenotypes, and giving BPD a hierarchical relationship vis-à-vis other personality disorders. These changes are incremental, diminish overlap and heterogeneity, sustain clinical and research development, and will improve utilization.

Loss and disorganization from an attachment perspective

In this article, it is hypothesized that disorganizing, disorienting, and unresolved states of mind about loss experiences, as classified by the Adult Attachment Interview (AAI) coding system, may offer insight into the bereaved mind and may guide clinical treatment approaches. This article discusses pre-loss attachment organizations and the disorganizing/disorienting markers of unresolved loss found in the AAI. Although sometimes subtle in nature, the unresolved, disorganized, and disorienting indices--defined as lapses in monitoring of reason, discourse and behavior--provide concrete markers for assessing the degree of resolution for loss experiences. An attachment-based grief treatment model can add to existing models implemented in prolonged grief disorder treatment.

How mothers with borderline personality disorder relate to their year-old infants

BACKGROUND

Women with borderline personality disorder have conflictual interpersonal relations that may extend to disrupted patterns of interaction with their infants.

AIMS

To assess how women with borderline personality disorder engage with their 12 to 18-month-old infants in separation-reunion episodes.

METHOD

We videotaped mother-infant interactions in separation-reunion episodes of the Strange Situation test. The mothers were women with borderline personality disorder, with depression, or without psychopathological disorder. Masked ratings of maternal behaviour were made with the Atypical Maternal Behavior Instrument for Assessment and Classification.

RESULTS

As predicted, a higher proportion (85%) of women with borderline personality disorder than women in the comparison groups showed disrupted affective communication with their infants. They were also distinguished by the prevalence of frightened/disoriented behaviour.

CONCLUSIONS

Maternal borderline personality disorder is associated with dysregulated mother-infant communication.

Representations of the caregiver-child relationship and of the self, and emotion regulation in the narratives of young children whose mothers have borderline personality disorder

Borderline personality disorder (BPD) represents a severe distortion in the development of attachment, self, and emotion regulation. Study of children at high risk of developing BPD may inform precursors to BPD. In a low socioeconomic status sample of 30 children aged 4-7 whose mothers have BPD and 30 normative comparisons, representations of the caregiver-child relationship and of the self, and emotion regulation were assessed with a story-stem completion measure. In contrast to comparisons and controlling for major depressive disorder, children whose mothers have BPD told stories with the following: (a) more parent-child role reversal, more fear of abandonment, and more negative mother-child and father-child relationship expectations; (b) more incongruent and shameful representations of the self; and (c) poorer emotion regulation indicated by more confusion of boundaries between fantasy and reality and between self and fantasy, more fantasy proneness, less narrative coherence, and marginally more intrusion of traumatic themes. In the sample as a whole, (a) a maladaptive caregiver-child relationship composite was associated with maternal identity disturbance and self-harm; (b) a maladaptive self-composite was associated with maternal self-harm; and (c) a maladaptive emotion regulation composite was associated with maternal identity disturbance, negative relationships, and self-harm. Results are discussed in terms of putative precursors to BPD and preventive interventions.

BPD's interpersonal hypersensitivity phenotype: a gene-environment-developmental model

This paper explores the development of BPD as it might emerge in the child's early interpersonal reactions and how such reactions might evolve into the interpersonal pattern that typifies BPD. It begins to bridge the relevant bodies of clinical literature on the borderline's prototypic interpersonal problems with the concurrently expanding relevant literature on early child development. We will start by considering how a psychobiological disposition to BPD is likely to include a constitutional diathesis for relational reactivity, that is, for hypersensitivity to interpersonal stressors. Data relevant to this disposition's manifestations in adult clinical samples and to its heritability and neurobiology will be reviewed. We then consider how such a psychobiological disposition for interpersonal reactivity might contribute to the development of a disorganized-ambivalent form of attachment, noting especially the likely contributions of both the predisposed child and of parents who are themselves predisposed to maladaptive responses, leading to an escalation of problematic transactions. Evidence concerning both the genetics and the developmental pathways associated with disorganized attachments will be considered. Emerging links between such developmental pathways and adult BPD will be described, in particular the potential appearance by early- to middle-childhood of controlling-caregiving or controlling-punitive interpersonal strategies. Some implications from this gene-environment interactional theory for a better developmental understanding of BPD's etiology are discussed.