Bpd Is Related to Secure

¶ … Bpd Is Related to Secure Attachment

HOW BORDERLINE PERSONALITY DISORDER IS RELATED to EARLY INSECURE ATTACHMENT

Overview of Borderline Personality Disorder

Diagnostic Criteria of BPD

Overview of Attachment Theory

Summary of Literature Reviewed

HOW BORDERLINE PERSONALITY DISORDER IS RELATED to EARLY INSECURE ATTACHMENT

The objective of this work is to write a critical review of the literature about borderline personality disorder (BPD) from an attachment theories perspective. This work will contain references from Bowbly, Ainsworth, and Main in the discussion of secure vs. insecure attachment. Insecure attachment will then be researched regarding insecure attachment as a contributor to BPD. It should also discuss the potential benefits of viewing BPD from an attachment perspective in terms of prevention and treatment of the BPD.

Introduction

Borderline personality disorder (BPD) is a psychiatric problem that is highly prevalent and chronic in nature. This debilitating problem is characterized by self-defeating patterns of a chaotic nature in their interpersonal relationships. Other characteristics of this problem include."..emotional lability, poor impulse control, angry outbursts, frequent suicidality, and self-mutilation." (Levy, 2005)

Overview of Borderline Personality Disorder (BPD)

In the view of Dr. William Sears: "the concept of attachment is a literal one." (Kendall, 2003) in fact Kendall relates the fact that Dr. Sears states that in order to "immunize" your child against "the social and emotional diseases that plague our society" that the parent should carry the child strapped close to their body. Kendall states the fact that "attachment theory is undergoing a renaissance of sorts, in both the lab and clinic. As a wealth of long-term studies now show, children who develop strong bonds with their parents are likely to form similar bonds with peers, partners, and eventually their own children." (2003)

In the year 2000 an entire issue of the Journal of the American Psychoanalytic Association" was devoted to attachment theory stating that a recent study conducting was reporting that: "mother rats who groomed their infants more than usual triggered the expression of a gene that enabled the babies to grow into less anxious adults with lower levels of stress hormones." (Kendall, 2003) Kendall relates that the work of Bowlby is receiving a "second look." (2003) Bowlby's attachment theory was not accepted by science and in fact got him into trouble after completion his medical studies and started his psychoanalytic training. (Kendall, 2003) Psychoanalysis mainstream belief at the time was that problems in the emotional area "stemmed primarily from internally generated conflicts or fantasies." (Kendall, 2003) the external realities (activities and events in the environment) were considered irrelevant insofar as the emotions of the child.

The argument of Bowlby in his 1958 paper entitled: "The Nature of a Child's Tie to his Mother" was that the primary need that the infant required was the mother's attention even above receiving nourishment. Bowlby never swayed from this belief. During the 1960s and 70s Mary Ainsworth, who conducted a study that identified three attachment styles or categories of the response of an infant upon reunion with the mother after a brief separation. Those attachment styles are: (1) secure; (2) avoidant; and (3) ambivalent. The secure infant protested when the mother departed yet sought close proximity upon her return. Avoidant infants did not express much emotion to begin with showed little acknowledgement of the mother's return. Finally, the ambivalent infant, protested at the mother's department provide to be difficult to comfort upon the mother's return. During the decade of the 1980s, a third attachment style was added by Mary Main, UC-Berkeley psychologist which is the "disorganized" attachment style. The 'disorganized' individual is one who has a history of neglect or abuse and exhibit chaotic behavior upon the return of the mother after a brief separation. In spite of empirical findings the attachment theory has "generated a blistering barrage of criticism from the very start." (Kendall, 2003) Bowlby's attachment theory was attacked furiously by feminists groups however, "the most rigorous challenge to Bowlby's ideas has come from a group of developmental psychologists, led by Harvard's Jerome Kagan." (Kendall, 2003) According to Kagan: "Infant experience is very critical only if your mother goes after you with a frying pan. But extremely adverse circumstances are rare." (as cited in Kendall, 2003) Kagan's belief is that the 'strange situation' measures of Ainsworth are not useful although studies have remained consistent over time upholding the validity of Ainsworth' three styles of attachment.

The study conducted by Jay Belsky in 1996 states findings that only 50% of the infants were categorized the same when retesting was conducted three months following. Thomas Insel, director of the National Institute of mental Health and others are "charting new directions for both the mental-health practice and policy" in the area of neurobiology and bonding which has "put the theory on ever-strong empirical footing." (Kendall, 2003) Insel's work has been exploratory in the role of "brain chemicals called neuropeptides in pair-bonding the discovery of these so-called "attachment hormones," such as oxytocin and vasopressin, has highlighted the physiological basis of various attachment behaviors, such as the infant's desire to be soothed." (Kendall, 2003) Recently Allan Schore released two books revealing neurobiological research that upholds that the "ultimate architecture of the child's brain" is determined by the mother or caregiver. Schore holds that "therapists can facilitate emotional growth, even treat serious mental illness such as borderline personality disorder, by serving as protective attachment figures. Not just drugs but a strong therapeutic relationship itself, regardless of the specific style of therapy, can alter faulty brain chemistry for the better." (Kendall, 2003) landmark study conducted by Harvard Medical school's Karlen Lyons-Ruth that involved 72 families that tracked the long-effects of home visits aimed at helping mother improve their communication style-by" through the expression of emotions that are more positive. By the age of five years the children of mothers receiving the support were found to be "less hostile and aggressive toward peers" than children whose mother's did not receive the support.

Diagnostic Criteria of Borderline Personality Disorder (BPD)

I. DIB-R

Stated as the diagnostic interview to be used for borderline personality diagnosis by Gunderson and Kolb is the DIB-R (revised 1989) in assessing borderline characteristics in patients. The DIB categorizes symptoms into four major groups as follows:

The Diagnostic Interview for Borderlines, Revised

Affect

Chronic/major depression

Helplessness

Hopelessness

Worthlessness

Guilt

Anger (frequent expression of anger)

Anxiety

Loneliness

Boredom

Emptiness

Cognition

Odd thinking

Unusual perceptions

Nondelusional paranoia

Quasipsychosis

Impulse action patterns

Substance abuse/dependence

Sexual deviance

Manipulative suicide gestures

Other impulse behaviors

Interpersonal relationships

Intolerance of alones

Abandonment, engulfment, annihilation fears

Counterdependency

Stormy relationships

Manipulativeness

Dependency

Devaluation

Masochism/sadism

Demandingness

Entitlement

The DIB-R is stated to be the most well-known method of testing for and diagnosing BPD and as well use of this specific test has allowed researchers to make identification of four behavior patterns specific to BPD which are those of:

Abandonment;

Engulfment;

Annihilation fears

Demandingness and entitlement,

Treatment regressions

Ability to arouse inappropriately close or hostile treatment relationships.

II. DSM-IV

The DSM-IV states nine criteria and requires that the individual have at least five of these evident. Traits are those as follows:

Traits involving emotions: Individuals with BPD have a very hard time controlling their emotions. According to one researcher: "People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement." (Linehan, nd) These traits are those of: (1) Shifts in mood lasting only a few hours; and (2) Anger that is inappropriate, intense or uncontrollable.

Traits involving behavior - Includes (1) Self-destructive acts, such as self-mutilation or suicidal threats and gestures that happen more than once; and (2)Two potentially self-damaging impulsive behaviors. These could include alcohol and other drug abuse, compulsive spending, gambling, eating disorders, shoplifting, reckless driving, compulsive sexual behavior.

Traits involving identity - Inclusive of:

1) marked, persistent identity disturbance shown by uncertainty in at least two areas. These areas can include self-image, sexual orientation, career choice or other long-term goals, friendships, values. People with BPD may not feel like they know who they are, or what they think, or what their opinions are, or what religion they should be. Instead, they may try to be what they think other people want them to be. Someone with BPD said, "I have a hard time figuring out my personality. I tend to be whomever I'm with."

2) Chronic feelings of emptiness or boredom. Someone with BPD said, "I remember describing the feeling of having a deep hole in my stomach. An emptiness that I didn't know how to fill. My therapist told me that was from almost a "lack of a life." The more things you get into your life, the more relationships you get involved in, all of that fills that hole. As a borderline, I had no life. There were times when I couldn't stay in the same room with other people. It almost felt like what I think a panic attack would feel like."

Overview of Attachment Theory

John Bowlby first developed the attachment theory which has been called "one of the most important developments within psychiatry, since Freud and represents a huge qualitative change in our understanding of childhood relationships and the development of personality. Attachment was believed by Bowlby to be a critical aspect of the normal development of human behavior. Attachment is inclusive of the following characteristics:

1) Proximity Seeking - the infant seeks to be near the maternal figure;

2) Separation distress or protests - when separated or distant from the material figure the infant becomes distressed and signals this by vocalizing these feelings and changes in affect.

3) a secure base - when the infant develops a healthy attachment, the mother becomes a 'secure base' from which the child can venture forth into the world and securely explore their surroundings.

Ainsworth is noted as the first to conduct empirical research assessing patterns of attachment behaviors in infant attachment relating to the mother being under stress. Infant attachment behavior was categorized as: (1) secure; (2) avoidant; and (3) ambivalent. Since then the behavioral patterns of infants has undergone intensive assessment and study with a core body of empirical findings replicating extensively the earlier research. The work of Bowlby (1973) acknowledged anger as being a natural response when the child, with the expectation of safety, when in close proximity to the attachment figure was jeopardized. It is believed by Bowlby that the root of anxious attachment is "dysfunctional anger." (Fonagy, 1999) Anxious attachment has been linked to behavior including violent behavior. Broussard (1995) found that anxious attachment is present in the majority of working class children.

Literature Review

Levy states in the 2005 Development and Psychopathology journal article: "The Implications of Attachment Theory and Research for Understanding Personality Disorder" that psychopathology researchers and theorists have now began to: "understand fundamental implications of BPD. Behaviors within the realm of those with this disorder include "...unstable, intense interpersonal relationships, feelings of emptiness, bursts rage, chronic fears of abandonment and intolerance for aloneness, and lack of a stable sense of self as stemming from impairments in the underlying attachment organization." (Levy, 2005) it is related by Levy (2005) that it has been noted among researchers that the characteristics of "Impulsivity, affective lability and self-damaging actions that are the hallmark of borderline personality occur in an interpersonal context." These are often known to occur after events in relationships whether they are real or imagined events. Levy (2005) holds that the individual difference is shown by evidence of research to be "rooted in interaction with caregivers" and have implications of importance in the individual's adaptations and development." (Ibid)

The work of Agrawal, Gunderson, Holmes, and Lyons-Ruth entitled: "Attachment Studies with Borderline Patients: A Review" states that it has been suggested by clinical theorists that disturbed attachments are central to borderline personality disorder (BPD) psychopathology. In this work thirteen empirical studies are reviewed in the attempt to examine the types of attachment of these studies. The types of attachments at these authors state are "most characteristic" of individuals with BPD are "unresolved, preoccupied and fearful." (Agrawal, Gunderson, Holmes, and Ruth-Lyons, 2004) in the BPD individual there exists a desire for intimacy while at the same time these individuals have a deep concern of dependency and rejection. It has been a suggestion since the inception of BPD diagnosis among clinical theorists that BPD is a disorder in which the core psychopathology arises: "within the domain of interpersonal relations." (Ibid) it has been as postulated by John Bowlby that all humans, just as primates, "are under pressures of natural selection to evolve behavioral patterns, such as proximity seeking, smiling, and clinging, that evoke caretaking behavior in adults, such as touching, holding and soothing." (Ibid) This is considered an affective tie between the infant and its caregiver thereby constituting an attachment. From these responses of the parents which are of a natural nature the infants development of internal models of both self and other form and function in the future as templates for relationships.

Bowlby holds that "the content of the internal working model of self is related to how acceptable or lovable one is in the eyes of primary attachment figures." It is through this model that the individual's perception of 'other' is related to "how responsive and available attachment figures are expected to be" (Ibid) if the child develops a 'secure' attachment then a positive self-image and a sense of being loved and this in combination with an expectations that is positive concerning the 'significant other' in their lives are usually receptive and respond positively to caring. Alternatively, the individual who does not develop a secure attachment: "contrasts dramatically with the malevolent or split representations of self and others, as well with the needy, manipulative, and angry relationships that characterize persons with BPD." (Ibid) Furthermore the models developed persist throughout the life of the individual forming their beliefs in regards to past, present and future interactions with the 'other' in their life. The individual with a secure attachment frees the child in their exploration of the world in confidence knowing that the availability of the caregiver is assured. A secure attachment is more likely to develop if the child has capacity in perceiving the thoughts of others. The core symptoms of BPD in 'Fonagy's theory to be inclusive of a diminished capacity to mentally represent other's feelings and thoughts as well as the individual having a lack of sense of their own self, impulsivity, and feelings of emptiness that are of a chronic nature. Individuals with BPD do not have the ability to bring about a "soothing introject" (Ibid) in situations of distress due to early attachments to caregivers that are "inconsistent and unstable" due to lack of a secure early attachment. Gunderson made the observation that insecure patterns of attachment."..specifically, please for attention and help, clinging, and checking for proximity that often alternate with a denial of, and fearfulness about, dependency needs 'closely parallel the behavior of borderline patients." (Ibid)

The work of Winston (2000) states the diagnostic criteria for borderline personality disorder to include at least five of the following:

1. Intense and unstable personal relationships;

2. Frantic efforts to avoid real or imagined abandonment;

3. Identity disturbance or problems with sense of self;

4. Impulsivity that is potentially self-damaging;

5. Recurrent suicidal or parasuicidal behavior;

6. Recurrent suicidal or parasuicidal behavior.

7. Affective instability;

8. Chronic feelings of emptiness;

9. Inappropriate intense or uncontrollable anger;

10. Transient stress-related paranoiac ideation or severe disassociate symptoms. (Winston, 2000)

The prevalence of BPD in the community was estimated by Widiger & Weissman (1991) to be 2% and among psychiatric patients to be 15%. (Winston, 2000) the following chart labeled Figure 1 is an 'aetiological model of borderline personality disorder.

Borderline Personality Disorder [aietiological Model]

Winston (2000)

Winston states that the "lack of a sense of self is a core feature of the psychopathology of BPD" which has been linked by psychoanalysts to "pathological splitting of the ego and object." (2000) This splitting is often noted in patients with BPD. This is believed to be due to childhood abuse and neglect as these are both common in borderline patients. In fact the following have been stated in findings:

1) 87% of BPD individuals have undergone some type of childhood trauma;

2) 40-71% have been sexually abused; and 3) 25-71% have been physically abused. (Winston, 2000)

The effect of abuse on the individual is greatly dependent upon the stage of psychological development that the abuse occurs within. Winston holds that the earlier the abuse then the more damaging to the individual because "the young child's cognitive immaturity and consequent inability of make sense of traumatic experiences." (Winston, 2000)

Effects that are a Possible from Childhood Trauma in BPD are those of:

Self-mutilation

Defective affect regulation

Lack of reflective capacity

Disassociation

Impulsivity

Disturbed Interpersonal relationships. (Winston, 2000)

Treatments for BPD

Treatments for BPD include:

1) Dialectical behavior therapy;

2) Psychoanalytic psychotherapy;

3) Therapeutic Communities;

4) Cognitive-analytic therapy;

5) Interpersonal therapies;

6) Schema-Focused cognitive therapy.

Description of Treatment Models for BPD

Dialectical behavior therapy:

This therapy claims as its basis the principle that "BPD is essentially the results of deficits in interpersonal and self-regulatory skills and that these skills can be taught in therapy. Defective affect regulation is seen as particularly important. Treatment consists of weekly individual and group therapy sessions based on skills-training model, together without-of-hours telephone contact with the therapist." (Winston, 2000) One study did show Dialectical behavior therapy to be "superior to 'treatment as usual' in reducing self-harm and time spent in hospital, but not subjective experiences such as depression and hopelessness (Linehan, et al., 1991; as cited in Winston, 2000) Noted as well were improved functioning, both global and social and improved levels of anger however, only one year following the treatment end the rates of self inflicted harm were not able to be differentiated in the DBT and the treatment-as-usual groups in the study although there was improvement in both groups.

Psychoanalytic psychotherapy

This therapy has been in use for many years in treating borderline patients however, has not been evaluated on a formal basis. According to reported study findings the data makes suggestion that only a small percentage of borderline patients respond well to psychoanalytic psychotherapy in the form traditionally used but that a modification of this method places emphasis on present experiences rather than those of the past to include the modification of the therapist in that the therapist's role is more active in the modified method for treatment of BPD. A specialized brief form of psychotherapy with a design focused toward meeting the borderline patient needs has been described by Stevenson & Meares (1992) This model is one that is based on self-psychology and the 'conversational model' (Hobson, 1985 as cited in Winston, 2000) This is a twice weekly therapy for the period of one year. Improvements were observed in affective instability, impulsivity and suicidal behavior. By treatment end 30% of patients "no longer met DSM-IIR (American Psychiatric Association, 1987) criteria for BPD." (Winston, 2000)

Therapeutic Communities:

Therapeutic Communities are a treatment option for BPD. In 1997 Dolan et al. made comparison of 70 patients receiving treatment at the Henderson Hospital with those who had been referred but had refused funding by the health authority. 80% of these patients had been diagnosed with BPD with many meeting personality disorder diagnostic criteria for other conditions. It is reported that 43% of patients "showed a clinically significant change in core borderline psychopathology at one year after discharge, compared with 18% of those who had refused funding." (Winston, 2000) Therapeutic treatment may be approached as well in Therapeutic community studies through calculation of the consumption of service and public costs both before and following treatment. It has been shown in recent studies that "substantial reductions in service consumption and costs following treatment in three National Service therapeutic communities; the Cassel and Henderson Hospitals in London and Francis Dixon Lodge in Leicester (Chiesa et al., 1996; Dolan et al. 1996, David et al., 1999; as cited in Winston, 2000)

Cognitive-analytic therapy (CAT

This type of therapy is for patients who are BPD is a method that "employs a collaborative approach between patient and therapist in order to make identification of "self-states" (Ryle, et al., 1997; as cited in Winston, 2000) the inability for these self-states to integrate is held to be 'inadequate parenting'. The rapid shifting between these self-states are held to be the basis for instability on the interpersonal level these patients exhibit in their life. This method allows the patient to learn a new method of relating with others through assisting the patient with linking early experiences with their current behavior.

Interpersonal therapies"

Among the most common presenting features of BPD in the individual is stated to be those of 'interpersonal difficulties' which cause suffering and "manifest themselves in complex and ambivalent relationships with professions." (Winston, 2000) the 'Structural Analysis of Social Behavior' reported in Benjamin (1996) as a technique used in making analysis of interpersonal behavior. Interpersonal patterns that are dysfunctional may be identified and then coded. The treatment is "an eclectic mix of techniques' with the therapist assisting in blocking behavior that is maladaptive (at the patient's request) in order that new ways of functioning can be established. The 'brief interpersonal therapy (IPT) was developed in 1984 by Kerlman et al. And has been used in an adapted form to treat patients with BPD and is a structured, time-limited therapy that "focuses on the relationships between symptoms and interpersonal difficulties." (Winston, 2000)

Schema-focused cognitive therapy:

This method is one that focuses on the identification and modification of the 'early maladaptive schemes' (Young, 1994; as cited in Winston, 2000) Schemas are defined as:."..broad pervasive themes regarding oneself and one's relationship with others, developed during childhood and elaborated throughout one's lifetime and dysfunctional to a significant degree" (Young, 1994)

Recent Study Findings

Pilkonis (2006) states that the core features of BPD are impairments in interpersonal function. The hypothesis of the work of Pilkonis (2006) is that: "many of the interpersonal features of BPD arise through maladaptive functioning of the attachment system (Bowlby, 1979, 1979; Cassidy & Shaver, 1999). The best understanding of the 'Attachment' theory as being a theory of the interrelation of interpersonal behavior and the influence it has on regulation of emotions. (Tidwell, Reis, & Shaver, 1996, p. 729).Inappropriate relationships and romances in the life of the individual with BPD are noted. Pilkonis (2006) states that:

Phenotypes should point the way toward greater understanding of etiology, maintenance, and remission (or exacerbation). This explanatory orientation has at least two implications: one, phenotypes should have developmental relevance (to help us understand etiology and onset), and two, they should be capable of generating and testing hypotheses about mechanisms and processes that maintain or exacerbate the disorder. This is a high standard, of course, and as a first step, it is probably more realistic to expect that research will establish the existence of risk factors by documenting associations between aspects of interpersonal behavior and BPD. Next steps will require longitudinal work that establishes certain risk factors as causal and that explicates the psychological mechanisms that underlie them. Phenotypes should demonstrate excellent sensitivity and good (but not perfect) specificity. If we take a dimensional approach and use latent variable methods, the underlying latent variables that are associated with key phenotypic features are also likely to influence other near neighbors that share some of the same characteristics (e.g., other cluster B personality disorders), and therefore, specificity will not be perfect. To establish their clinical significance, phenotypes should demonstrate convergent and predictive validity with functioning in normative social roles and with day-to-day interpersonal behavior. It is important to establish relationships not only with measures of symptoms and other features of personality but also with measures of functioning, especially those corroborated by key informants, e.g., members of the patient's social network, clinicians." (Pilkonis, 2000)

The current interpersonal phenotype in the DSM-IV involves two criteria which are those of: (1) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation; (2) Frantic efforts to avoid real or imagined abandonment." (Pilkonis, 2000) fuller characterization of interpersonal problems includes:

Intolerance of aloneness

Abandonment, engulfment, and annihilation concerns

Counterdependency

Unstable close relationships

Recurrent problems in close relationships (e.g., devaluation, entitlement)

Troubled psychiatric relationships (Pilkonis, 2000)

There are two methods of collecting data on adult attachment, which are those as following:

First method: Grew out of the developmental literature and clinical literature and relies on the Adult Attachment Interview (AAI, George, Kaplan & Main, 1985); and Second method: Grew out of the social psychological literature, uses a self-report questionnaire for assessing various aspects of adult attachment in romantic relationships and other social domains in adulthood. Two other questionnaires used quite frequently are: (1) Experiences in Close Relationships Scale-Revised (ECR-R, Fraley, Waller & Brennan, 2000) and (2) the Relationships Questionnaire (RSQ; Griffin & Bartholomew, 1994)

According to Pilkonis (2006) "Global measures of functioning in major social roles are often used to assess aspects of interpersonal behavior and two commonly used exemplars are the Social Adjustment Scale (SAS: Weissman & Paykel, 1974) and the Longitudinal Interval Follow-Up Evaluation (LIFE, Keller et al., 1987) the Revised Adult Personality Functioning Assessment (RAPFA, Hill, Harrington, Fudge, Harrington, Pickles & Rubber, 2000) was developed with the more specific agenda of linking social behavior to interpersonal models of personality dysfunction. The RAPFA is an investigator-based interview that asks about functioning over substantial periods of time in up to six domains: work, romantic relationships, friendships, non-specific social interactions, negotiations, and day-to-day coping. The RAPFA was designed to assess interpersonal behaviors according to the rules and demands underlying each social domain, severity and type (e.g., discordant, avoidant) of impairment within each domain, and disorganization across domains." (Ibid) the following table labeled Figure 1 lists the levels of analysis of interpersonal functioning.

Levels of Analysis of Interpersonal Functioning

Source: Pilkonis (2006)

The work of Gunderson (2006) states that degree that the BPD is caused by heredity is called the "level of heritability" and it is estimated at 68%. It is not the disorder itself that is inherited but instead it is the 'biogenetic dispositions' or the chances of development dependent upon other factors. Past studies have stated findings that disorders relating to regulation of emotions are "disproportionately higher in relatives of BPD patients." (Gunderson, 2006) According to Gunderson extreme sensitivity to separation or rejection is probably the root of the disturbed attachment temperament. Complex tasks such as impulse control, regulation of ones' emotions and social cue perception require 'normal neurological function' (Ibid). Studies conducted concerning BPD patients have served to identify increased incidents of neurological dysfunctions which are described as 'subtle [and] discernable upon close examination." (Gunderson, 2006)

It is further related by Gunderson (2006) that individuals with BPD have."..a diminished serotonergic response to stimulation in this area of the cerebrum, the upper section, where information is interpreted coming in from the sense and from which conscious thoughts and voluntary moments are thought to emanate." (Ibid) the limbic system is located at the brain's center and is referred to as "the emotional brain" and consists of the amygdala, hippocampus, thalamus, hypothalamus, and parts of the brain stem." (Ibid) There are two areas that are believed to be inclusive of factors that to contribute to the development of BPD including the factors of:

1) Psychological Factors - BPD is not believed to initially appear during a:."..specific, discrete phase of development." (Gunderson, 2006) Those with BPD frequently report a childhood that was characterized by the individual feeling that neglect occurred during their childhood. A large part of these feelings are attributed to a feeling or sense of failing to be understood. In cases of sexual abuse, "the child may need to engage in splitting (denying feelings of hatred and revulsion in order to preserve the idea of being loved." (Gunderson, 2006) it is stated as well that "approximately 30% of people with BPD have experienced early parental loss or prolonged separation from their parents." (Gunderson, 2006) Individuals who are adopted have been found to be more likely to be diagnosed with BPD than others; and 2) Social/Cultural Factors - Approximately 1.5% of the population has borderline personality disorder which are contributed to by societal and cultural factors. For example in today's highly modern and highly mobile society of instability due to divorce and economic factors, the development of this disorder is very high in certain individuals.

Gunderson (2006) reviews the 'status of theories' in relation to the origins and pathology of BPD stating that: "At this juncture, clinical theorists believe that biogenetic and environmental components arte both necessary for the disorder to develop. These factors are varied and complex [and it is believed that]."..Most individuals should be presumed o have a neurobiological propensity for the disorder." (Gunderson, 2006) While the environment of the home and the caregivers might be nurturing even so many develop the illness and at the same time, children who have totally inept caregivers do not show any indications of BPD. Gunderson (2006) states that the explanation thought to be best "appears to be that there is a confluence of environmental factors and a sensitive, emotionally labile child who has difficulty interpreting the world, including the meaning of his or her caregiver's behaviors." p.7

Bradley and Westen (2005) state that over the last 80 years: "The conceptualization of borderline personality disorder" has changed significantly. The work of Westen (1998b) relates that BPD is developmental and forms when their caregivers "withdraw or attack in response to their legitimate expressions of need and affects (e.g. For autonomy, separation, and anger) and subsequently play out many of these relationship paradigms in their adult lives." (Ibid) it is explained by Bradley and Westen (2005) that there are the BPD cases that are unresolved among which is preoccupied (analogous to anxious/ambivalent in infancy and childhood). A combination of unresolved nd preoccupied attachment has been associated with BPD in adolescents as well. (Nakash-Eiskovits, Dutra & Westen, 2002; Westen, Nakash, Thomas & Bradley, in press) as cited in Bradley & Westen (2005)

Fonagy used attachment theory as a framework in their proposal of a model of BPD emphasized by the development capacity in mentalization, or reflection function which is the ability of the individual to both make sense of self and other's mental states expressed as feelings, beliefs, wishes, ideas, etc.) Mentalization is the ability one has to empathize with the 'other' or visualize from the others perspective. The caregiver's response is affective in the interpersonal model that is mapped in the mind of the child. Westen & Bradley state that: "As caregivers respond to children, they both observe and mirror the child's mental and particularly emotional states, and allow the child to explore the mind of the caregiver." This serves to assist the child in the acknowledgement of their own mind and informs the child of the minds of others. When the child does not develop, reflective functioning is left with:."..a tacit belief in the one to one correspondence between their own perceptions of others' feelings and motives and reality and concomitant inability to consider alternate interpretations of why people are doing what they are doing.

Kernberg (1975) held that the associated negative feelings (aggression, abandonment, sexual abuse) reflect temperament or frustrations of a severe nature in the environment and memories of events and feelings that were both very good and very bad and that these experiences with caregivers, significant other is stored in a separate area of the human brain by "affective valence" (Bradley and Weston, 2005) the individual who develops 'borderline character structure' are at a personal crossroads with the dilemma stated as: "One the one hand, they want to hold onto their 'good' representations, and hence work hard to ward off any association with negative feelings. However these "good" introjects are constantly threatened with rage and hostile impulses. Therefore, for Kernberg, these individuals are characterized by a "motivated effort to protect "good" object representations" and these "good" object representations are defended in the individual's own reality and existence.

Kohut (1977) believed that a coherent sense of individual self is developed and as well the capacity for emotion-regulation and self-esteem regulation through "transmuting internalizations of soothing and mirroring functions of early caregivers." (p.942, Ibid) in order for the child to develop in the most optimally prescribed method the child will necessarily, experience both parents are being admirable with develops the child's self-esteem and the standards of the 'ideal self' in the mind of the child. Theorists have posited various hypotheses as to the etiology of BPD and severe character pathology in general. It was observed by Freud and Burlingham (1944) and Spitz (1956) that orphaned infants during the second World War having first experienced a disrupted attachment in early childhood later found great difficulty in their ability to "form lasting relationships. (Bowlby, 1969, 1973, 1980) Bradley and Westen (2005) state that: "From an attachment perspective, disrupted attachments and emotionally misattuned, threatening, unstable or unpredictable caregivers provide fertile soil for the development of incoherent (disorganized) internal working models, basic mistrust towards others (Erikson, 1962) the kind of global negative views of self characteristics of many patients with BPD."(Bradley & Westen, 2005) Bradley and Westen report the following facts in the section 'testing and refining clinical hypotheses' stating that:

1) "consistent with clinical hypotheses, disrupted attachments in childhood have shown an association with BPD." (Ibid)

2) "A meta-analytic review found that 20-40% of patients with BPD experienced traumatic separations from or both parents in childhood (Gunderson & Sabo, 1993)" (Ibid)

3) "Childhood histories involving lengthy separations from, or permanent loss of one or both parents differentiate patients with BPD from patients with schizophrenia, depression, and other PDs (Akiskal, et al., 1985; Bradley, 1979; Frank & Paris, 1981; Goldberg, Mann, Wise & Segall, 1985; Gunderson, Kerr & Englund, 1980; Links, Steiner, Offord & Eppel, 1988;; Paris, Nowlis & Brown, 1988; Soloff & Millward, 1983; Zanarini, Gunderson, Marino, Schwartz & Frankenburg, 1989) as cited in Bradley & Westen (2005)

According to the work of Peter Fonagy entitled: "Attachment, the development of the self, and its pathology in personality disorder" the symptoms of the BPD individual:."..may be understood in terms of a defensive strategy of disabling mentalizing or metacognitive capacity" such as those as follows:

1. Their failure to take into consideration the listener's current mental state makes their associations hard to follow.

2. The absence of concern for the other, which may manifest as extreme violence and cruelty, arises because of the lack of a compelling representation of suffering in the mind of the other. A key moderator of aggression is therefore absent. The lack of reflective capacity in conjunction with a hostile world-view may predispose individuals to child maltreatment but such inhibition may be a necessary component of all violence against persons. Military training has the apparent and explicit aim of fashioning men into machines and the enemy into an inanimate or sub-human object. Seeing the other as imbued with thought and feeling is very likely imposes a break.

3. Their fragile sense of self (identity diffusion to use Kernberg's term), may be a consequence of their failure to represent their own feelings, beliefs and desires with sufficient clarity to provide them with a core sense of themselves as a functioning mental entity. This leaves them with overwhelming fears of mental disintegration and a desperately fragile sense of self.

4. Such patient's mental image of object remains at the immediate context dependent level of primary representations - he/she will need the object as they are and will experience substantial difficulties when confronted with change.

5. Absence of prominence 'as if' in the transference requires meta representations, the capacity to entertain a belief whilst at the same time knowing it to be false. Psychotherapy requires such pretence and its absence manifests as so-called 'acting out' of the transference.

Fonagy states that in an ongoing study (Fonagy et al., 1996) AAI's were administered to a sample of 85 consecutively admitted non-psychotic inpatients at the Cassell Hospital in London, which is run along the principles of a psychoanalytic therapeutic community." (Fonagy,

The interviews were differentiated by three combined characteristics: (1) higher prevalence of sexual abuse reported in the AAI narratives, (2) significantly lower ratings on the reflective self-function scale; and (3) a significantly higher rating on the lack of resolution of abuse, but no loss scale of the AAI. (Fonagy, nd) Fonagy states that the findings of this study are "consistent with out assumption that individuals with experience of severe maltreatment in childhood who respond to this experience by an inhibition of reflective self function are less likely to resolve this abuse, and are more likely to manifest borderline psychopathology. " (Ibid) Maltreatment in childhood may have long-term sequelae with the outcome being only partially understood. Unresolved experience of childhood abuse affects the ability of the child is the formation of relationships that are meaningful in nature. Often there is a pattern established of distrust leading to a point of turning away mentally from the significant other and 'decoupling' of the 'mentalizing module' resulting in the individual being void of contact in their life. This is said to account for the observed neediness of the individual with BPD who "no sooner do they become involved with another then the malfunctioning of their inhibited mentalizing capacity leads them into terrifying interpersonal confusion and chaos. Within intense relationships, their inadequate mentalizing function rapidly fails them, they regress to the intersubjective state of the development of mental representation and they are no longer able to differentiate their own mental representations from those of others and both of these from actuality. These processes combine and they become terrorized by their own thoughts about the other experienced (via projection) in the other, particularly their aggressive impulses and fantasies; these become crippling and most commonly they reject or arrange to be rejected by their object. Psychoanalysis or psychotherapy can break the vicious cycle by reinforcing reflective capacity." (Ibid)

Levinson and Fonagy explored the criminality of those with BPD suggesting "attachment to individuals as well as social institutions may be critical in the reduction of the risk of delinquency. Collected were 22 AAI's from prisoners that were either convicted or on remand with a diagnosed psychiatric disorder. Findings of the study were:

1) There were significantly more secure attachments in the normal control group but the two clinical groups did not differ in terms of overall level of security.

2) 36% of the prison group vs. 14% of the psychiatric group were classified as 'Dismissing' with normal controls in between (23%).

3) 45% of the prisoners vs. 64% of psychiatric controls were classified as 'Preoccupied' with only 14% of non-criminal controls receiving this classification.

4) 82% of psychiatric patients but only 36% of prisoners and 0% of non-clinical controls received 'Unresolved' classifications.

5) 82% of prisoners and only 36% of psychiatric patients were rated as having been abused with only 4% of normal controls. (2/3 of abuse was physical, 1/3 sexual in both clinical groups).

6) Neglect was more prevalent in the prison group but rejection was more frequently reported by psychiatric patients.

7) Current anger with attachment figures was dominant in psychiatric patients but relatively more among prisoners.

8) Prisoners had significantly lower ratings on the reflective function scale (RSF) than either psychiatric patients or those from the non-clinical group, but RSF ratings of normals was still significantly higher than those of psychiatric patients.

9) When the prison group was split into those with violent index offences (murder, malicious wounding, GBH, armed robbery, indecent assault to child), vs. non-violent ones (possession, importation, obtaining property by deception, theft, handling stolen goods) the rating on reflectiveness of the former group was found to be significantly lower than the latter. (Levinson & Fonagy, nd)

The work of Fonagy suggests an attachment theory model of severe personality disturbance, which suggests that:

1) Secure attachment is the basis of the acquisition of metacognitive or mentalizing capacity;

2) the caregiver's capacity to mentalize may foster the child's bonding with the parent;

3) Maltreatment may undermine the acquisition of a mentalizing capacity;

4) Symptoms of borderline personality disorder may arise as a consequence of inhibited mentalizing;

5) Violent crime and anti-social personality disorder may be possible because the capacity to reflect upon the mental states of the victim is compromised;

6) Psychotherapeutic work may facilitate the reactivation of this inhibited. (Fonagy, nd)

The work of Bateman and Fonagy (2003) entitled: "The Development of an Attachment-Based Treatment Program for Borderline Personality Disorder" states that treatment of BPD is controversial thus, an evidence-based treatment program has been developed that is rooted in the attachment theory and integrates research on "constitutional factors with environmental influences." (Bateman and Fonagy, 2003) BPD is believed to be a disorder of the "self-structure" due to environmentally induced distortion of psychological functioning which decouples key mental processes necessary for interpersonal and social function." (Ibid) Strategies for treatment include mentalization focusing on the development of the individual's internal representation stability as well in aiding the forming of a coherent sense of self and in forming stable relationships with better understand of self- and other's motivations. Bateman and Fonagy (2003) state: "Destabilization of the self leads to emotional volatility, so treatment also needs to focus on identification and appropriate expression of affect. This article describes some of the techniques used to enhance mentalization within the context of group and individual psychotherapy. Targeting of current symptomatology and behavior is insufficient. Therapists need to retain their own ability to mentalize, maintain mental closeness, focus on current mental states, and avoid excessive use of conflict interpretation and metaphor while paying careful attention to the use of transference and countertransference."

The work of Diamond, Stovall-McClough, Clarkin and Levy (2003) entitled: "Patient-therapist attachment in the treatment of borderline personality disorder" reviews a longitudinal study which reports preliminary findings "on the impact of attachment state of mind and reflective function on therapeutic process and outcome with borderline patients in the Transference-Focused Psychotherapy (TFP)" which is stated to be a "manualized, psychoanalytically oriented treatment based on an object relations model of understanding patients with severe personality disorders." (Ibid) the Adult Attachment Interview (AAI) is used in this study for assessment of the changes of mind state with relating to attachment and reflective function over a twelve-month time-period in BPD individuals in TFP. Used in this specific study was an adaptation of the AAI in an interview called the "Patient-Therapist Adult Attachment Interview (PT-AAI). Findings of the study include the presentation of two cases that: "...illustrate how the quality of mentalization or reflective function in the therapeutic dyad may be seen as a bidirectional process in that therapists' and patients' levels of reflective function are mutually and reciprocally influential." (Ibid)

The work of De Zulueta (2006) entitled: "Borderline personality disorder as seen from an attachment perspective" published in the Criminal Behavior and Mental Health Journal acknowledges that increasing evidence exists to support the fact that borderline personality disorder can be understood "as damage to the attachment system." It is also noted in this work that the symptoms of distress upon occurrence of separation are very similar to those of narcotic withdrawal and are known to be inclusive of aggressive behavior. De Zulueta states: "Chronic stress in children can cause dis-regulation of the normal stress response and maladaptive brain activities. Secure, avoidant, anxious-ambivalent attachment in childhood can now be measured. Insecure children show needless aggression; avoidant children can become either abusers or victims. Disorganized attachment is a mixture of avoidant and anxious-ambivalent behavior and may lead to adult borderline personality disorder. Patterns of attachment are self-perpetuating and may be transmitted across generations." (2006) Stated as treatment goals for borderline personality disorder are "the integration of dissociated self states." (Ibid)