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Borderline Personality Disorder

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Joshua Wilson

on 10 November 2014

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Transcript of Borderline Personality Disorder

Risk Factors Across Development
Borderline Personality Disorder
Effects of Trauma on Parenting
Child Temperamental Factors
Later Childhood and Adolescence: BPRC's
Risk Factors and Presentation in Adulthood
Interpersonal Context, Invalidating Environments and Escalating Transactions
Attachment
Autonomy
Dissociation
Summary: Risk and Protective Factors
disturbed attachment
comorbid psychiatric problems
undeveloped theory of mind
Protective
healthy relationships
prolongued, repeated stress
Conclusions
References

Aber, J. L., Gershoff, E. T., Ware, E., & Kotler, J. A. (2004). Estimating the effects of September 11th violence on the mental health and social development of New York City’s youth: A matter of context. Applied Developmental Science, 8(3), 111-129.

*Beauchaine, T.P., Klein, D.N., Crowell, S.E., Derbidge, C., & Gatzke-Kopp, L. (2009). Multifinality in the development of personality disorders: A Biology X Sex X Environment interaction model of antisocial and borderline traits. Development and Psychopathology, 21, 735-770.

Belsky, D. W., Caspi, A., Arseneault, L., Bleidorn, W., Fonagy, P., Goodman, M., et al. (2012). Etiological features of borderline personality related characteristics in a birth cohort of 12-year-old children. Development and Psychopathology, 24(1), 251-265.

Bradley, S. (2000). Affect regulation and the development of psychopathology. New York: Guilford.

Bradley, R. & Westen, D. (2005). The psychodynamics of borderline personality disorder: A view from developmental psychopathology. Development and Psychopathology, 17(4), 927-957.

Buckley, M., & Walsh, M. (1998). Children’s understanding of violence: A developmental analysis. Applied Developmental Science, 2(4), 182-193.

Cicchetti, D., Beeghly, M., Carlson, V., Coster, W., Gersten, M., Rieder, C., & Toth, S. (1991). Development and psychopathology: Lessons from the study of maltreated children. In. D.P. Keating and H. Rosen (Eds.),

Constructivist perspectives on developmental psychopathology and atypical development. Hillsdale, NJ: Lawrence Erlbaum.

Cicchetti, D., & Rogosch, F. A. (1997). The role of self-organization in the promotion of resilience in maltreated children.

Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality: Elaborating and extending linehan’s theory. Psychological Bulletin, 135(3), 495-510.

Development and Psychopathology, 9, 797-815. Cohen, P., Chen, H., Gordon, K., Johnson, J., Brook, J., & Kasen, S. (2008). Socioeconomic background and the developmental course of schizotypal and borderline personality disorder symptoms. Development and Psychopathology, 20(2), 633-50.

Dodge, K.A., Pettit, G.S., & Bates, J.E. (1994). Effects of physical maltreatment on the development of peer relations. Development and Psychopathology, 6, 43-56.

Egeland, B. (1991). From data to definition. Development and Psychopathology, 3, 37-43. Eisen, M. L., & Goodman, G. S. (1998). Trauma, memory, and suggestibility in children. Development and Psychopathology, 10, 717-738.

Garbarino, J. (1991). Not all bad developmental outcomes are the result of child abuse. Development and Psychopathology, 3, 45-50.

Hesse, E. & Main, M. (2006). Frightened, threatening, and dissociative parental behavior in low-risk samples: Description, discussion, and interpretations. Development and Psychopathology,18(2), 309-343.

Hodges, S. (2003). Borderline personality disorder and posttraumatic stress disorder: Time for integration? Journal of Counseling & Development, 81(4), 409-417.

Jacobvitz, D., Leon, K., & Hazen, N. (2006). 363-379. Does expectant mothers’ unresolved trauma predicted frightened/frightening maternal behavior? Risk and protective factors. Development and Psychopathology, 18(2), 363-379.

Lamb, M.E., Sternberg, K.J., Orbach, Y., Hershkowitz, I., Horowitz, D., & Esplin, P.W. (2002). The effects of intensive training and ongoing supervision on the quality of investigative interviews with alleged sex abuse victims. Applied Developmental Science, 6(3), 114-126.

Lenzenweger, M.F. & Cicchetti, D. (2005). Toward a developmental psychopathology approach to borderline personality disorder. Development and Psychopathology, 17(4), 893-898.

Levy, K.N. (2005). The implications of attachment theory and research for understanding borderline personality disorder. Development and Psychopathology, 17(4), 959-986.

Linehan, M. (1987). Dialectical behavior therapy for borderline personality disorder: Theory and method. Bulletin of the Menninger Clinic, 51, 261-276.

McCloskey, L. A., & Stuewig, J. (2001). The quality of peer relationships among children exposed to family violence. Development and Psychopathology, 13, 83-96.

Minzenberg, Michael J., Poole, John H., & Vinogradov, Sophia. (2008). A neurocognitive model of borderline personality disorder: Effects of childhood sexual abuse and relationship to adult social attachment disturbance. Development and Psychopathology, 20(1), 341-368.

Putnam, F.W. (1993). Dissociative disorders in children: Behavioral profiles and problems. Child Abuse and Neglect: The International Journal, Special Issue: Clinical recognition of sexually abused children, 17(1), 39-45.

Putnam, F.W. (1995). Development of dissociative disorders. In D. Cicchetti & D.J. Cohen (Eds.), Developmental psychopathology, Vol. 2: Risk, disorder, and adaptation (pp. 581-608). Oxford: John Wiley & Sons.

Ryan, R.M. (2005). The developmental line of autonomy in the etiology, dynamics, and treatment of borderline personality disorders. Development and Psychopathology, 17(4), 987-1006.

*Trickett, P.K., Noll, J.G., & Putnam, F.W. (2011). The impact of sexual abuse on female development: Lessons from a multigenerational, longitudinal research study. Development and Psychopathology, 23, 453-476.

Sternberg, K., Lamb, M., & Dawud-Noursi, S. (1997). Using multiple informants and cross-cultural research to study the effects of domestic violence on developmental psychopathology: Illustrations from research in Israel. In S. Luthar, J. Burack, D. Cicchetti, & J. Weisz (Eds.), Developmental psychopathology: Perspectives on adjustment, risk and disorder (pp. 417-436). Cambridge, UK: Cambridge University Press.

*Wright, M.O., Fopma-Loy, J. & Oberle, K. (2012). In their own words: The experience of mothering as a survivor of childhood sexual abuse. Development and Psychopathology, 24, 537-552.
Joshua Wilson
Kendra Holmgren
PY 741
DSM-V Diagnostic Criteria for BPD
1. Frantic efforts to avoid real or imagined abandonment.

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self-damaging (spending, sex, substance abuse, etc)


Other Conceptualizations of BPD
Beauchaine et al. (2009):
Impulsivity
Ryan (2005) :
Lack of a stable sense of self, identity, or commitment
Ryan (2005) :
Disordered autonomy
Levy (2005) :
Impaired relationships stemming from attachment issues
Bradley and Westen (2005):
“soft bipolar spectrum pathology with extremely rapid cycling”
Hodges (2003):
Chronic form of PTSD


BPD has a very heterogenous presentation.

Prevalence and Comorbidity
Prevalence
Population prevalence ranges from 1.6 to 5.9%
10% of outpatient and 20% of inpatients
30-60% of those diagnosed with PD’s have BPD--
the most common personality disorder
75% are female

Comorbidity
56% also meet criteria for PTSD
50% meet criteria for histrionic personality disorder (Hodges, 2003)
Long observed co-occurrence with depression/mood disorders
40-90% of BPD patients self-injure or make a suicide attempt

Diagnostic Issues
Lack of clear thresholds
:
Many of the diagnostic criteria are highly abstract and open to interpretation (Beauchaine et al., 2009)
BPD is considered a “projective” diagnosis for this reason (Hodges, 2003)

Categorical rather than dimensional diagnosis

Extensive comorbidity
with other PD's and other disorders

Highly stigmatizing diagnosis
, especially compared to PTSD

Personality Disorders
DSM-V Definition
“An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, which manifests in at least 2 of the following areas: cognition, affectivity, interpersonal functioning, impulse control."

"...inflexible and pervasive across a broad range of personal and social situations"

"...leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning..."

"...stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood..."
Other Conceptualizations of PD's
Traits are sometimes discussed as part of PD's


But they are not explicitly in the DSM-V definition

However, the DSM-V considered incorporating an alternative approach to diagnosing PD's:
Defined PD's as involving:
At least one pathological personality trait
For example, Negative Affectivity
Each trait contains multiple facets (e.g., Separation Insecurity)
Continuum
And impairment in specific areas:
Identity
Self-Direction
Empathy
Intimacy

Intake Session with Sheila
PD's in this Presentation
We won't focus on a specific definition of PD's

But note that the alternative approach combines categorical and dimensional approaches, and may be better suited to a developmental perspective

Especially for BPD: the categories of impairment (Identity, Self-Direction, Empathy, and Intimacy) are all central to the disorder's symptoms
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6. Affective instability due to marked reactivity of mood.

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger or difficulty controlling anger.

9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following:
Various scholars have offered different ideas for what is at the "core" of BPD:
Sheila:
Crowell et al., 2009; APA, 2013; Hodges, 2003; Bradely and Westen, 2005
An 18-year old senior in high school
After noticing scars on Sheila's arms, a concerned college counselor called Sheila's mother, Penny.
Penny raised the issue with Sheila, who became very angry.
An argument ensued and quickly escalated to Sheila threatening suicide.
Penny immediately made a therapy appointment for Sheila.
“Why are you having trouble with Mr. Schulz?"
Because he’s borderline.
“Why do you consider him borderline?”
Because I’m having so much trouble with him.
.
Hodges, 2003
Presenting Concerns:
Heterotypic Continuity of BPD
BPD is rarely diagnosed before the age of 18

Some authors suggest that personality disorders are identifiable before young adulthood…(Beauchaine et al., 2009)

However, some symptoms of BPD do not translate easily into behaviors observable in young childhood
Frantic efforts to avoid abandonment -->persistent separation anxiety
A pattern of unstable, intense interpersonal relationships --> volatile relationship with primary attachment figures, siblings, or peers

Self-injury/suicidality does not emerge until later childhood

In addition, symptom-based studies show temporal instability.

So we are following Beauchaine’s and the DSM V’s alternate PD model’s lead and considering BPD as a developmentally and gender-moderated expression of underlying gene/trait X environment interaction.

Underlying impairments develop through a context of repeated relational stress and trauma and can result in BPD precursors in children before ultimately developing into adult BPD

Self-injurious behavior
Stress related to conflict with mother
Anxiety around the college application process
Would like mother to complete applications for her and gets very angry when mothers refuses to do so.
Complains of mother being controlling and "nosy"
process and fears of rejection
Low self-esteem and reports feeling "unlovable"
Heritability of BPD
Impulsivity, Emotional Lability, and Trait Anxiety
BPD Precursors in Young Children (Belsky et al. 2012)
Behavioral and Emotional Problems at Age 5
Lack of control:
(indexes emotional lability, restlessness, short attention span, negativism)
Approach
(quick adjustment to new situations, friendliness, self-confidence, self-reliance)
Inhibition
(flat affect, passivity, shyness, and fear)
Impulsivity
Externalizing problems
Internalizing problems

Cognitive Functioning at Age 5
Lower IQ:
(vocabulary and block design)
Executive Functioning
(working memory)
Theory of Mind
(false beliefs and inferences)

Note: cognitive functions such as attention and effortful control are critical for emotion regulation, so existing impairments in cognitive control may be a factor that contributes to increasingly impaired emotional regulation and reactivity.
Children with more of these problems were more likely to develop Borderline Personality Related Characteristics at age 12.

Thus, some of these problems may constitute precursors of BPD in young children in the right circumstances (since many of them also have multifinal outcomes).

How do these problems develop?
Family history of psychiatric disorder constituted a significant diathesis for the development of BPRCs at age 12.

Children with positive histories exhibited more BPRCs and were more like to be in the extreme borderline group.

Children who experienced harsh treatment were at a greater risk for developing BPRCs if they had a positive family psychiatric history.

Family history may be an indicator of vulnerability for more intense emotional response to later environmental stressors.

However, results suggest that family psychiatric history communicates risk for BPRCs even in the absence of harsh treatment.

BPD traits such as impulsivity range from 35 to 69% heritable--this is huge, given the disparate symptoms. (Beauchaine et al., 2009)

There is no single distinct BPD phenotype--diagnosis requires 5 of 9 highly related but ultimately distinct symptoms that range from cognition to behavior to affect.
Beauchaine et al. consider trait impulsivity to be the primary vulnerability for both BPD and ASPD

Multifinal gene X environment X gender interaction

Genetic Influences
Serotonin:
There is “overwhelming evidence” that 5HT deficits in children and adults are associated with borderline features such as mood disorder, suicidal and nonsuicidal self-injury, and impulsive aggression (Crowell et al., 2009)

Low serotonin also leads to low trait anxiety, and serotonin is often at significantly low levels in suicide victims (Beauchaine et al., 2009)

Dopamine:
Underactivation of the dopamine system is building evidence for an association with trait impulsivity and negative affectivity in people with BPD (Crowell et al., 2009)

Different genes affect the reuptake, catabolization, reactivity, and release of dopamine and serotonin.

Variation in any of these genes may contribute to varying levels of trait impulsivity, emotional lability, and trait anxiety.

Penny's Perspective
Family System's Meeting
Summary of Child Factors
Penny reports that Sheila has drastic mood swings and is often very irritable.
Penny describes being single parent and being challenged with Sheila's difficult behavior for as long as she can remember.
As an infant, Sheila was very upset when Penny left the room, but also very difficult to soothe when she returned.
As a child, Sheila had extreme temper tantrums.
Penny never knew how to discipline Sheila effectively.
Penny denies ever abusing Sheila.
Certain early childhood impairments, such as impulsivity and negative affectivity, appear to increase the likelihood of later development of BPRC's.

BPRC's are heritable and predicted by family history of disorder--the genes associated with impulsivity and emotional lability may be what is inherited.
Serotonin and dopamine dysfunction may be the particular neurological mechanisms responsible.
Impulsive and emotionally sensitive children in high-risk environments may have trouble inhibiting extreme emotions in the face of harsh parenting, and may pull for more punitive and controlling parenting or simply overstress their parents. (Crowell et al., 2009)
Both parent and child have contributions to the early relationship, which can have drastic effects on important aspects of development...
Penny:
Sometimes my mom reminds me of my grandfather, and he was actually crazy. He was really depressed all the time and heard voices. They're both so hard to deal with!!
Penny discloses being sexually abused from ages 7 to 15 by her biological father.
Feels like she is not a good mother and has failed her daughter.
Penny describes being overwhelmed by Sheila's difficult behavior and at times resorted to yelling at her and grounding her indefinitely no matter what the issue was.
Ever since she was little, I could tell she was different...she was so irritable and fussy, even as a baby. But you know, my mother says I was the same way.
Penny and Sheila
Childhood Sexual Abuse:
Trickett et al, 2011
Factors impacting negative outcomes:
father figure as perpetrator
early age of abuse
length of abuse
General Effects of Childhood Sexual Abuse:
PTSD Symptoms (dissociation, hyper vigilance, nightmares etc.)
HPA Dysregulation
early age of first voluntary intercourse
increased risk for obesity
accelerated pubertal development
increased risk of teen pregnancy and teen motherhood
I was always a very shy, anxious child growing up. I guess you could say I was in ‘my own world’, ya know, constantly spacing out. I didn’t really have many friends and struggled academically.
Effects of Abuse on Parenting:
Wright et al, 2012
Decreased sensitivity and warmth toward children
Less closely attached
Lack of satisfaction and feelings of competence in the mothering role
Challenges in Parenting Relevant to BPD:
Victims of Abuse as Parents:
Problems with encouraging age-appropriate autonomy
Promoting healthy sexuality
Building the mother-child relationship and developing intimacy
Setting appropriate boundaries
Role reversal
Lack of a model of healthy relationships
Negatively experiencing children’s expressions of negative emotions

My boyfriend is the only one that doesn't hate me.
My teachers are trying to make me fail on purpose.
I never know what's going to set her off, it's like I'm always walking on eggshells around her.
Interpersonal Context:

Attachment
Levy, 2005
Hallmarks of BPD take place in interpersonal contexts:
emotional lability
fear of abandonment
intense and unstable relationships
Impaired attachment is major risk factor for BPD!
Features of Disorganized and Disoriented Attachment:
Most closely linked with BPD
When child is faced with an irresolvable dilemma
caregiver is unavailable, unpredictable, or frightening
infant cannot find a coherent strategy for either understanding or eliciting security, and lacks coherent, organized strategies for coping with stress
this contributes to child's inability to form coherent models of relationships for use in the future
has continued difficulties in predicting, understanding, and therefore optimally adapting to significant others
Bradley & Westen, 2005
Hesse & Maine, 2006
Cicchetti et al, 1991
Risk Factors for D/D Attachment:
Hesse & Maine, 2006
Jacobvitz et al., 2006
--> leads to fear of the parent while still regarding parent as the primary source of safety

--> leading to approach-avoidance conflicts and
dissociative behaviors in the child!
Hesse & Maine, 2006
entering into a dissociative state ("freezing", haunting tone)
threatening behaviors ("predatory" play behaviors")
sudden expressions of fear or withdrawal
FR Parenting Behaviors include:
Mother's unresolved trauma
Mother's own attachment to her mother
Parent abuse
and
Child experiences of "frightening" (FR) parenting behaviors
Interviews from Qualitative Studies (Wright et al., 2010):
triggered while playing with child
dissociation
what is appropriate play?
role reversal
Penny is one such mother...
An Example of Disorganized/Disoriented Attachment
Consider:
What features of d/d attachment are present in this video clip?
What do you notice in the child's response to his mother?
Jacobvitz et al, 2006
Protective Factors in Attachment
secondary secure attachment to someone unrelated to d/d attachment
mother having had a secure attachment
Dissociation:
divided psychological awareness
a "defensive flight" from overwhelming experiences or affect
discrete state of consciousness
a process of diminishing various mental functions
defensive purpose
automatization
compartmentalization
alterations of the Self
protection from pain
overwhelmingly linked to early trauma
Bradley & Westen, 2005
Putnam, 1995
Hesse & Maine, 2006
Trickett et al, 2011
Developmental Perspectives of Dissociation:
critical period of vulnerability before age 10
normal child behavior or dissociative symptoms?
children may be especially vulnerable to dissociation
BPD and Dissociative Identity Disorder:
However, not all BPD patients are disorganized

There is evidence that fearful/avoidant and preoccupied/anxious attachments are also highly common in BPD. (Equifinality) (Levy, 2005)

Self-report (adult attachment inventory), interviews, and observational data find that BPD is most consistently related to insecure, but no one type dominates

Disorganized is most common in cases of abuse or FR parenting

But there are many cases of BPD with no abuse--here, anxious and avoidant are more common

Child/parent transactions --> attachment

BPD can be an equifinal outcome of multiple insecure attachments

Avoidant
Anxious/Preoccupied
Disorganized
Harsh parenting and FR parenting
My mom is always freaking out about the smallest things...I never know when I can count on her, so I've always felt distant from her.
It may be the case that there are levels of adaptive development within each attachment style which may better predict BPD than attachment style alone.
Different ways to express the same attachment
Different degrees of differentiation/integration of attachment style and internal working model
BPD and other disorders might be more particularly related to these dimensions.

Ultimately, more prospective studies of attachment and BPD are needed. However, even existing prospective work still seems to favor disorganized attachment as one of the major mechanisms of development of BPD in situations involving direct or vicarious trauma (Levy, 2005; Hesse and Main, 2006).

Equifinality in Attachment--> BPD
Autonomy and BPD
In contrast to many other personality disorders, BPD behaviors are often experienced as impulsive, compulsive, or dissociated.

This is consistent with an understanding put forth by Ryan (2005) that BPD is primarily a disorder that reflects:

"...a developmental struggle in which both individual vulnerabilities and environmental deprivations and insults conspire to produce conditions insufficient to nurture optimal self-organization and autonomy..."
Based on Ryan’s self-determination theory, autonomy and relatedness are basic human needs that require proper environmental supports in early development.

But when those conditions are not met, those needs are thwarted and pathology (such as BPD) is often the result.

Autonomy in this context refers to the state of being able to self-regulate and self-control truly volitional actions that come from an authentic self.
(Mal) development of Autonomy
Autonomy is thought to begin development in early childhood.

The child’s first system of self-regulation and expressing her needs is the successful communication of those needs to the parent. (Ryan, 2005)

Must be able to establish a self-regulatory
system together with the parent, who must
in turn be attuned to the child's needs.
(Ryan, 2005)

Children who can successfully attain soothing through cooperation with their mother are on the way to developing autonomy.
This process can be disrupted via contributions from the child as well as the parent.

Children with
more sensitive
mothers later develop more curiosity, intrinsic motivation, resiliency, etc. (Ryan et al., 2005)

Children who have difficult temperaments may make it more difficult for their mothers to be sensitive and responsive to them, especially children who are highly irritable or difficult to soothe.

i.e. high negative affectivity, emotional lability, and impulsivity... Beauchaine et al. (2009)
Autonomy Supportive Parenting
Children with Dissociative Disorders exhibit similarities to adults with BPD:

rapid mood swings
irritability
impulsive aggression
suicidal ideation
self-injurious behavior
premature sexual development
There are specific parenting behaviors that are important for developing autonomy in the child at different stages of development. (Ryan, 2005)

Autonomy supportive parenting for infants/young children includes:
Appreciating the child’s frame of reference: mirroring/appreciating/validating the child’s emotions/needs
Fostering the child’s knowledge of internal states by responding appropriately to the child’s emotions and needs.
Mutual responsivity.

This process depends on parents having enough psychological resources to devote attention and effort toward autonomy support, as opposed to acting out of the parent’s own needs.
Parents with unresolved trauma (Wright et al., 2010)
Of course, directly abusive parents are also not autonomy supportive.
Turbulent therapy relationships
Alter personalities have contradicting emotional reactions to stimuli, such as views of the same attachment figure
Dissociative shifts associated with rapid affect and behavioral shifts
Lacks stable sense of self and autonomy
Decreased sense of personal authorship over actions
decreased subjective experience of behavior and impaired development of sense of agency
Putnam, 1995
Dissociation along a continuum:
BPD symptoms as mildly dissociative processes?
Common risk factors
early trauma
disrupted attachment
Multifinal, but highly related?
Sometimes when I fight with my mom, I say things I don’t really mean to say, like someone else’s words are coming out of my mouth…
Putnam, 1995
Parents who do not reflect, validate, and respond to their child’s needs may contribute to the lack of stable sense of self characteristic of BPD because those children never learn to accurately anticipate, recognize and value their own internal states. (Ryan, 2005)

Instead, these children are left with feelings of hopelesness, reactivity, and a need for external sources of self-regulation, such as through their relationships

Summary of Autonomy
Overly involved/controlling/punitive parenting are seen as opposed to autonomy support.

Children of autonomy insupportive mothers...(Ryan, 2005)
show impaired self-regulation
are less motivated to achieve,
less securely attached,
more likely to engage in risky behaviors
less likely to experience well-being and mental health

Autonomy-insupportive parenting can be caused by an impaired parent (e.g. trauma) and/or a difficult child (e.g. impulsive, reactive)

In addition, autonomy-insupportive parenting may exacerbate other existing child problems, such as attachment, by contributing to escalating cycles of conflicting/coercive parent-child interactions.

Early abuse is neither necessary nor sufficient for developing BPD!
Problems with attachment, autonomy, and dissociation are defensive responses and they are adaptive!
approach-avoidance
problems with a stable sense of self/agency (dissociation)
Crowell et al, 2009

However, these adaptations set up problematic transactional cycles that continue to have many negative impacts...
Let's Review!
Borderline Personality Related Characteristics (BPRCs) in Children and Borderline Personality Disorder in Adults:

BPRCs in childhood increase risk for adult BPD, but unclear whether they share specific etiological features
similar rates of heritability
early experiences as risk factors
general "diathesis-stress" onset indicated in both
common domains of impairment
comorbid psychiatric problems
BPRCs in Children and Adolescents:
jealousy
falls for new friends intensely and expects too much too quickly
changes friends constantly
fears of rejection and/or abandonment
feels others are out to get him/her
Acts overly seductive or sexy
attracted to unsuitable romantic partners
emotions spiral out of control
cannot think when becomes upset
unable to soothe self
unstable image of self
exaggerated expression
irritable
angry and hostile
engages in self harm
Belskey et al., 2012
Can we predict the development of BPD in children?
?

Equifinality in Attachment--> BPD
Factors Impacting Early Peer Relationships:
Both BPRCs and disrupted attachment can prevent healthy peer relationships
During elementary school years friendships and peer-evaluation play critcal roles and social rejection predicts later problems
juvenile delinquency
dropping out of school
psychiatric problems
Physically maltreated children:
more disliked by peers
less popular
socially withdrawn
Abused females exhibited increased "coy" factors
Dodge et al., 1994
Belsky et al., 2012
Disorganized and Disoriented Attachment
Peer Relationships
Multiple Paths to BPRC's
Even children who are not directly abused experienced impaired peer relationships.

Children who witnessed violence between their parents had more conflict with peers and reported more loneliness, especially those children who were also abused by or experienced excessive punishment from their mother. (McCloskey and Stuewig 2001).

This included conflict with their best friend, i.e. a more intimate relationship.

These impaired peer relationships seem to be precursors of the relational pattern of adult BPD.
Some of the effects of family trauma were substantiated through the mother’s punitive parenting behaviors...
which were previously implicated in:
disorganized attachment
impaired autonomy
dissociation.

We also know that children with some of the temperamental characteristics of BPD pull for more punitive parenting, and thus may have set the stage for further impairment of peer relationships later in life.
McCloskey and Stuewig (2001) did not specifically address BPD or early childhood.

So while children with the early relationships we discussed in the previous section may be at greater risk for these types of impaired peer relationships...

The development of BPD can also begin here in later childhood.

However, in Sheila's case, her dysfunctional peer relationships serve to continue to solidify maladaptive transactions she developed earlier.
I hate most of the kids in school. And when my best friend got into college, we got into a huge fight. We've had big arguments since we were kids.
Adolescence
Developmental Challenges
Ongoing Challenges
view selves as damaged or evil
lack stable sense of self
deficits in capacity to regulate influences of mood on cognitions
difficulties in creating coherent "self narrative"
sense of self can be interrupted by dissociation
Experience of Self in BPD
Bradley & Westen, 2005
Mothers with BPD:
more intrusive
less sensitive
display less positive affect with their child
their infants are more likely to display disorganized attachment and dissociative behaviors
Adolescents experience developmental tasks that are particularly relevant to BPD:
Sexual maturation/romantic relationships
Increased affiliation with peers
Increased differentiation from parent
Increased need for autonomy and identity formation
There is evidence of significant risk for cyclical, inter-generational transmission of BPD
Abused females showed higher rates of contradictory approach and avoidance signals with strangers (full smiling while shrugging their shoulders, or showing their tongues while crossing their legs)

These "coy" factors were associated with earlier ages of first consensual sexual intercourse, which was associated with increased STD risky behaviors and increased dissociative symptoms

Sexually abused females reported 20% more subsequent, lifetime traumas than comparison females. (Trickett et al, 2011, 463)

Sexual revictimization was significantly and positively correlated with with PTSD symptoms, dissociation, and sexually permissive attitudes. (Trickett et al, 2011, 463)
Levy, 2005
Sexual Development and Revictimization
Parenting and Autonomy
Cross sectional studies of mothers of adolescents with BPD found that parents were less empathic, more egocentric, and less differentiated from their daughters, in line with findings regarding early autonomy support (Levy, 2005)

In teenagers, parental autonomy support is related to less depression and anxiety and more self-worth and identity (Ryan, 2005)
Qualitative Distinctions of Affective Instability in BPD:
only fluctuations in negative mood
depressed mood marked by one-sided ("split") representations of self and others
mood lability is highly reactive
Bradley & Westen, 2005
We don't have enough data on Sheila's mother, Penny, to know whether she also has BPD, but we do know that she was a victim of trauma . . .
And that her daughter, Sheila, does have BPD.
Peer Relationships
Heightened sensitivity to rejection during a period of increasing importance of peer-rated status (Belsky et al., 2012)

Jealousy and manipulative behavior leading to increased conflict with peers (Belsky et al., 2012)

Self injury: peer contagion and seeking social support (McCloskey and Stuewig, 2001)
Neurocognitive Deficits
What are the neurocognitive deficits in BPD?
Executive functioning (ability to plan and maintain goals)

Ability to think clearly while experiencing strong emotions

Paranoia

General reality testing

Memory deficits (especially in uncued recall of complex and recently learned information)

Deficits in attention

Impairment in visuospatial
processing


(Bradley & Westen 2005)


CSA survivors:
exhibit lower crystallized and fluid cognitive abilities
at increased risk for academic underachievement
slower development of receptive language
These seem to stem from the direct effects of stress as well as behavioral problems such as school avoidance
(Trickett et al., 2011)

Beauchaine et al. (2009) also suggest that effects of stress on developing brain can create abnormalities in cortical structures

Belsky's BCRP's include inability to think clearly when emotional and constantly changing goals and plans

BCRP's are predicted by childhood early cognitive impairment.






How did they develop?
Neurocognitive Deficits and Attachment
Minzenberg et al (2008). hypothesized that certain brain areas are differentially related to BPD symptoms, especially negative affectivity, impaired effortful control, and delayed recall deficits

Negative affectivity = amygdala and top-down regulation of hippocampus

Effortful control = anterior cingulate cortex/prefrontal cortex

Delayed recall = hippocampus

BPD patients also show structural abnormalities in all these areas: OFC, PFC, ACC, amygdala, and hippocampus

These limbic and cortical areas are also implicated in attachment:
Effortful control areas develop rapidly in early childhood, in part based on interactions with early caregivers
These structures activate during attachment behavior according to neuroimaging studies

Minzenberg’s study found:
BPD patients with
anxious attachment
were more likely to show
impaired recall
BPD patients with
avoidant attachment
were more likely to show
impaired executive functioning
(e.g., effortful control)
Cognitive deficits were found regardless of emotional content of stimuli

This suggests that negative affectivity and cognitive control have partially distinct origins and efffects, and that the same applies for particular cognitive deficits

(Effortful control is also associated with autonomy!)
Why these links?
Adult avoidant attachment as part of a coping strategy to compensate for impaired executive function that would otherwise be used for emotion regulation in stressful social situations
Genes are not the direct cause of cognitive/brain structure impairments, since these develop later in adolescence/childhood. (Beauchaine et al., 2009)

Minzenberg (2008) found evidence supporting a model in which abuse as well as neurocognitive performance had interactive AND independent effects on adult attachment disturbance.

Multifinal routes to adult BPD symptoms--neurocognitive impairment begins as a consequence of early trauma as well as other factors, but then becomes an independent risk factor for later BPD.

Temperamental factors co-act with the environmental inputs to create stressful situations that lead to impaired cognitive functioning, which in turn creates the potential for more stressful situations. (Beauchaine et al., 2009)


Early Trauma/Stress
Early Neurocognitive Deficits
Ongoing Attachment Problems
Adult BPD Neurocognitive
Deficits
Treatment
Early Family Interventions
I said I was going to kill myself to show her that she would miss me. And doing stuff like that is the only way to get her to pay attention to me anyway.
I especially feel out of control with her love life, but I had to put my foot down with her first boyfriend. He was such a bad influence on her.
Generally, diathesis stress models underscores the importance of early family-based interventions in preventing BPRCs in childhood from progressing to BPD in adulthood. (Belsky et al., 2012)

Prioritizing children with positive family psychiatric history and identified 5HT/DA irregularities may help target intervention (Belsky et al., 2012, Beauchaine et al., 2008)

Early childhood interventions for children who have experienced abuse should focus on (Cicchetti et al, 1991)
Understanding and expressing emotions
Understanding the underlying causes of behavior
Developing an understanding of self
Develop effortful/cognitive control (Minzenberg et al., 2008)
Develop social skills: empathy, prosocial engagement (Sue and McCloskey)
The family role in facilitating the child’s self-regulation. (Belsky et al., 2012)

Developing a Mothering Self
Based on Wright et al. (2012), mothers who have experienced abuse are important prevention targets for BPD

Helping them deal with their own abuse is the first step, so that they have psychological resources available for their child and can avoid being triggered

Next, they need a model of healthy parenting/discipline practices, which they may lack experience with
This includes appropriate play and soothing behaviors, to avoid FR parenting and causing D/D attachment.
Appropriate autonomy supportive parenting.
Psychoeducation about changing developmental needs of their children as they age will help them prevent relapses into punitive parenting behaviors
And help them understand healthy autonomy, peer relational, and sexual development

Development of BPD
Child Trait Impulsivity, Reactivity, Family History
Parenting Difficulties, Especially due to abuse/disorder
Early transactional cycles of parent-child difficult interactions
Leads to problems with attachment, dissociation, autonomy, emotional regulation, cognitive deficits...
BPRC's
Continued, escalating transactions between parent and child
New transactions with peers and romantic/sexual relationships
Adult BPD
Intergenerational Transmission
Trauma/Abuse
Sheila's greatest risk factor may ultimately be that her mother is a survivor of sexual abuse.

But she herself was not abused, which may have made her trajectory much worse.

Her relationship with her mother may be an important area of treatment to focus on.

Her relationship with her boyfriend may also be a protective secure attachment.

Discussion Questions
identify and alter pathological relationship paradigms (e.g. victim-victimizer)
increase complexity and coherence of patient’s representations of themselves, others, and relationships
identify and alter pathological modes of emotion regulation
validation and acceptance enhance sense of self and autonomy
mindfulness
Goals:
Bradley & Westen, 2005, Ryan, 2005
Barriers To Treating BPD
traits of disorder not considered problematic by the individual with BPD --> doesn't willingly seek treatment
relational impairments and dyregulation significant challenges to working with BPD patients
therapist must find the difficult balance between confrontation and showing empathic nurturance
APA, 2013, Bradley & Weston, 2005
feels unpleasant emotions very intensely
becomes overwhelmed and disorganized by emotion
ruminates when distressed
tends to become needy, dependent and clingy when distressed
lashes out at others when distressed
has difficulty seeing others’ perspectives
Issues of emotion dyregulation and experience of emotion in treating BPD:
immediate and intense transference reactions, such as
idealization of therapist

characteristic anger, hostility, and feelings of rejection and abandonment
Bradley & Weston, 2005
Elicits strong countertransference reactions


approach
withdrawal
feeling manipulated
helplessness
hatred, anger, resentment
anxiety, worry, fear
urges to “rescue”
inevitably leads pt to feel therapist has "failed" pt
acts out towards therapist, engages in self harm, or other maladaptive coping
Therapist has mixed reactions to patient:
Therapist
Bradley & Weston, 2005
The Therapy Relationship
Transference
and
Countertransference
Patient perceives negative, conflicting response
Further distress
Further relationship instability
Patient
Other Treatment Issues:
Dialectical Behavior Therapy (DBT)
Three Core Beliefs in BPD:
1. The world is malevolent and dangerous
2. I am powerless and vulnerable
3. I am inherently unacceptable
Goals of DBT:
validate and debunk self-invalidating thoughts and beliefs
teach coping skills
improve emotion regulation and tolerance of negative emotion
mindfulness
Four Modules of DBT Treatment:
1. Interpersonal Effectiveness
2. Distress Tolerance
3. Emotion Regulation
4. Mindfulness
support partners
secure attachments
Interpersonal
*PBD may make such relationships difficult to maintain!
Mothers With a History of Sexual Abuse
higher levels of satisfaction with social support
lower levels of dissociation reported lower levels of punitive parenting
Supportive Childhood Friendships
Autonomy-supportive romantic relationships
Family Environment
models healthy expression of emotion

helps child with emotion regulation
"Staff-splitting": when staff members become polarized into those that see the patient as manipulative and hostile and those that see a passive victim that they must “save”
Therapists working with BPD patients are at the greatest risk for transgressions of therapeutic boundaries (most severe of which involve sexual contact)
Risk Factors of Early Childhood
The notion of BPRC's assumes a certain degree of heterotypic continuity in the development of BPD symptoms. How do we draw the line between:
Normal and pathological development
The effects of trauma/general impairment and BPD-specific impairments?

What similarities and differences are there between BPD and responses to trauma/PTSD?

In addition to transactions between the therapist and client, what are some other barriers to treatment/prevention/early intervention for people with BPD across development?

We discussed autonomy, attachment, and dissociation as some of the primary risk factors in early development. What are some ways that these risk factors co-act with each other and with the environment?
Peer rejection

trauma

punitive punishment

positive family psychiatric history

dissociation

childhood sexual abuse
trait impulsivity

temporal instability
underlying genetic factors
attention impairment
lack of effortful control
parental malevolence
experience of harsh treatment
5HT deficits
underactive dopamine system
low seratonin

witnessing violence in childhood
unpredictable or frightening parenting

lack of healthy relationship models
mothers with unresolved trauma
parents that are not attune to child's needs
high negative affectivity
impaired development of autonomy
overly controlling parents

lower IQs
Presence of BPRCs in childhood
behavioral and affective dysregulation
peer contagion of self-injury

heightened sensitivity to rejection
impairments in visiospacial processing

low fluid and crystallized cognitive abilities
anxiousness
Possible Risk Factors

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