Attachment Studies with Borderline Patients: A Review - Part 1

All this build up talking about Attachment but what exactly does it have to do with Borderline Personality Disorder?!? I appreciate your patience, but you should know be by now. I need to be thorough and give you the most complete information I can find, so when we get to things like my post for today…. We’re all on the same page and have a strong understanding of where the research is coming from. Today’s article is brought to you from the Harvard Review of Psychiatry with contributions from the Department of Psychiatry at Harvard Medical School; McLean Hospital, Belmont, MA (Drs. Agrawal and Gunderson); Department of Psychiatry, Cambridge Hospital, Cambridge, and MA (Drs. Holmes and Lyons-Ruth). Pay special attention to the things I underline and expound on. I do this because some passages are cumbersome and filled with science jargon that doesn’t always feel accessible and I just want the information to be easy to read for everyone. If you see this >>>> it means I’ve interpreted the paragraph for easier reading. I’m going to do this in two parts because it’s extremely long.  I’ll talk about the Scope and Studies today and the Results and Discussion tomorrow. You can find the whole article HERE. 

Attachment Studies with Borderline Patients: A Review

Hans R. Agrawal, MD, John Gunderson, MD, Bjarne M. Holmes, PhD, and Karlen Lyons-Ruth, PhD

Abstract

Clinical theorists have suggested that disturbed attachments are central to borderline personality disorder (BPD) psychopathology. This article reviews 13 empirical studies that examine the types of attachment found in individuals with this disorder or with dimensional characteristics of BPD. Comparison among the 13 studies is handicapped by the variety of measures and attachment types that these studies have employed. Nevertheless, every study concludes that there is a strong association between BPD and insecure attachment. The types of attachment found to be most characteristic of BPD subjects are unresolved, preoccupied, and fearful. In each of these attachment types, individuals demonstrate a longing for intimacy and—at the same time—concern about dependency and rejection. The high prevalence and severity of insecure attachments found in these adult samples support the central role of disturbed interpersonal relationships in clinical theories of BPD. This review concludes that these types of insecure attachment may represent phenotypic markers of vulnerability to BPD, suggesting several directions for future research.

Ever since the inception of the borderline personality disorder (BPD) diagnosis, clinical theorists^1-5 have suggested that the disorder's core psychopathology arises within the domain of interpersonal relations. These theories were prompted by the centrality of interpersonal demands and fears within clinical contexts. While there has been growing evidence and interest in biogenetic bases for borderline pathology,^6,7 these perspectives do not diminish the potential role that disturbed relationships have as risk markers or as mediating factors in BPD's pathogenesis.

>>>> Even though there is a significant amount of evidence that points towards a genetic component for the development of BPD, environmental factors still represent a potential cause for disturbed relationship and developmental issues in BPD.

In recent years the methodology for reliably measuring attachment styles has provided a welcome opportunity to characterize empirically the interpersonal problems of BPD patients. Because the insecure attachments of borderline patients are so manifest, so central to the problems that they present for treatment, and so central to theories about the pathogenesis of BPD, the empirical examination of these attachments has considerable clinical and theoretical significance. The resulting literature—still growing rapidly—is the subject of this review.

ATTACHMENT THEORY AND PSYCHODYNAMIC FORMULATIONS OF BPD

In the background of the attention being given to attachment problems in borderline patients is the seminal developmental theory of John Bowlby.^8-10 He postulated that human beings, like all 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. These reciprocal behaviors promote the development of an enduring, affective tie between infant and caregiver, which constitutes attachment. Moreover, from these parental responses, the infant develops internal models of the self and others that function as templates for later relationships.⁹ These models, which tend to persist over the life span, guide expectations or beliefs regarding interactions in past, present, and future relationships. For Bowlby,⁹ 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. The content of an individual's model of other is related to how responsive and available attachment figures are expected to be.

The goal of attachment is the creation of an external environment from which the child develops an internal model of the self that is safe and secure. Secure attachment to the caregiver liberates the child to explore his or her world with the confidence that the caregiver is available when needed. A secure attachment should engender a positive, coherent, and consistent self-image and a sense of being worthy of love, combined with a positive expectation that significant others will be generally accepting and responsive. This portrait of secure attachment contrasts dramatically with the malevolent or split representations of self and others,¹¹ as well as with the needy, manipulative, and angry relationships, that characterize persons with BPD.^1,2,5

Fonagy and colleagues^12-14 have proposed that a child is more likely to develop a secure attachment if his or her caregivers have a well-developed capacity to think about the contents of their own minds and those of others. This secure attachment, in turn, promotes the child's own mental capacity to consider what is in the mind of his or her caregivers. In contrast, individuals with BPD demonstrate a diminished capacity to form representations of their caretakers' inner thoughts and feelings. In this way a child defensively protects himself or herself from having to recognize the hostility toward, or wish to harm, him or her that may be present in the parent's mind. In Fonagy's theory this diminished capacity to have mental representations of the feelings and thoughts of self and others accounts for many of the core symptoms of BPD, including an unstable sense of self, impulsivity, and chronic feelings of emptiness.

Several clinical theorists have posited intolerance of aloneness as a defining characteristic for BPD that provides coherence to the DSM's descriptive criteria.^2,15 Gunderson³ subsequently suggested that this intolerance reflects early attachment failures, noting that individuals with BPD are unable to invoke a “soothing introject” in times of distress because of inconsistent and unstable attachments to early caregivers or, in Bowlby's terms, because of insecure attachment. Gunderson observed that descriptions of certain insecure patterns of attachment—specifically, pleas 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.

 >>>> Comparing theories of object relations and attachment, Lyons-Ruth^16,17 has distinguished normal processes of separation-individuation in early development from the disorganized conflict behaviors displayed toward attachment figures by toddlers at risk for later psychopathology. She has argued that disorganized insecure attachment in infancy (see below) represents a deviant developmental pattern that, when present, may be an identifiable risk factor for the later development of BPD.

>>>> Lyons-Ruth compares the theories for object relations (like object constancy/permanency) and attachment. In healthy development there should be a secure sense of Self even during times of separation from attachment figures. However when the attachment to caregivers is more disorganized a behavioral conflict arises and indicates a potential psychopathology risk later in life. She argues that this disorganized insecure attachment style in infancy represents an abnormal developmental pattern that may be an identifiable risk fact for the later development of BPD.

DEVELOPMENTAL RESEARCH ON ATTACHMENT RELATIONSHIPS AND THE AAI

Attachment in Infancy and Childhood

>>>> The empirical assessment of patterns of attachment behaviors began with Ainsworth and colleagues'¹⁸ typology of infant attachment behaviors toward their mothers when under stress. Under this typology, there were three organizations of infant attachment behavior: secure, avoidant, and ambivalent attachment (Table 1). In subsequent years, these infant behavioral patterns have been intensively researched, and a core body of empirical findings has been extensively replicated.²¹

>>>> Ainsworth and colleagues originally discovered 3 classifications for infant attachment behavior: Secure, Avoidant, and Ambivalent.

Comparison of Attachment Types in the Traditions of Developmental Versus Social Psychology

Attachment in infancy/childhood—developmental tradition*	Attachment between adults—social psychological tradition†
Secure (autonomous)‡	Secure
Open communication of positive and negative affects with the caregiver	Positive self-image and a sense of being worthy of love, combined with a positive expectation that others will be generally accepting and responsive
Insecure	Insecure
Avoidant (dismissing)‡	Dismissing/avoidant
Restricted communication of vulnerable affects and deactivated attention to attachment needs	Positive self-image and a sense of lovability, combined with a negative expectation of significant others as demanding, clingy, and dependent
Ambivalent (preoccupied)‡	Anxious/preoccupied
Exaggerated communication of vulnerable affects and hyperactivated attention to attachment concerns	Negative self-image and a sense of unlovability, combined with a positive evaluation of others (in terms of their strength and independence)
Disorganized/disoriented (unresolved)‡	Fearful/avoidant
Contradictory, apprehensive, aimless, or conflicted behaviors in response to attachment needs	Negative self-image combined with a skepticism that significant others can be trusted to be loving and available

>>>> As infant attachment assessments were extended to high-risk or psychiatric samples, many of the infant behavioral patterns observed did not conform to any of the three attachment patterns characteristic of infants in low-risk settings. These repeated observations led Main and Solomon¹⁹ to review a large number of at-risk infant videotapes and develop coding criteria for a fourth category labeled disorganized/disoriented (Table 1). Disorganized attachment behaviors were subsequently found to be associated with family environments characterized by increased parental risk factors such as maternal depression, marital conflict, or child maltreatment. These attachment behaviors are also the behaviors most consistently associated with childhood psychopathology, including internalizing and externalizing symptoms at school age, as well as overall psychopathology and dissociative symptoms by late adolescence.¹⁷

>>>> As studies continued to include high-risk individuals it was discovered that many of the infant behavioral patterns didn’t fit the previous 3 models. A new category was created to encompass these new patterns: Disorganized/disoriented. These disorganized attachment behaviors were subsequently found to be associated with family environments characterized by increased risk factors in the parents: such as maternal depression, marital conflict, or child maltreatment.

Attachment in Adulthood

A major step in the developmental research literature on attachment occurred with the introduction by Main and colleagues²² of the Adult Attachment Interview (AAI) in 1985. The AAI is a semi-structured interview developed to assess the adult counterparts of the secure, avoidant, and ambivalent attachment strategies observed during infancy and childhood. The interview lasts approximately one hour and poses a series of questions probing how the individual thinks about his or her childhood relationships with parents or other central attachment figures. The interview is coded not for the positive or negative content of childhood experiences or memories, but in terms of narrative analysis—that is, for how the individual organizes his or her attention and discourse regarding attachment topics over the course of the interview.

Adult strategies for discussing positive and negative attachment experiences in childhood are observable in the interview and parallel the infant strategies described earlier. Flexible and coherent discourse around both positive and negative attachment experiences is termed autonomous (the equivalent of secure in childhood); deactivating strategies are termed dismissing (the equivalent of avoidant); and hyperactivating strategies are termed preoccupied (the equivalent of ambivalent).

Shortly after the introduction of the AAI, Ainsworth and Eichberg²³ reported that the parents' lapses in the monitoring of discourse or reasoning during discussions of loss or trauma on the AAI predicted disorganized attachment behaviors in their infants. This finding has now been well replicated, leading Main and Goldwyn²⁴ to develop a fourth category for the AAI labeled unresolved with respect to loss or trauma. Unresolved attachment patterns are the only patterns that are also given a secondary subclassification (namely, unresolved/autonomous, unresolved/dismissing, or unresolved/preoccupied) that indicates which organized attachment classification is the best-fitting alternative classification. That is, since an unresolved classification is understood as indicating a collapse of strategy—as seen in the failure to use a single, consistent strategy over the course of the interview—the secondary classification is used to indicate the best guess as to the strategy that has failed.

SOCIAL PSYCHOLOGICAL RESEARCH ON ATTACHMENT RELATIONSHIPS

Attachment Theory as Conceptualized Between Adults

Although Bowlby was primarily interested in young children, he maintained, as noted earlier, that the core functions of the attachment system continue throughout one's life span.⁹ In a series of independent developments in the field of social psychology, Hazan and Shaver²⁵ were first to apply concepts of attachment developed from studies of the parent-child relationship to the romantic relationships found between adults. For example, feeling securely attached arises after receiving feedback from other adults that one is loved and capable.²⁶ This inner sense of security contributes to a stable, consistent, and coherent self-image and to the ability to reflect upon and correctly interpret others. The social psychological tradition has defined secure, dismissing/avoidant, anxious/preoccupied, and fearful/avoidant attachment (Table 1).^8,20 To simplify, these types will hereafter be referred to as dismissing, preoccupied, and fearful.

Adult Attachment Self-Report Measures

>>>> In this study Hazan and Shaver expanded the attachment study to romantic relationships between adults. People were given an Attachment Self-Report (ASR) and asked to pick one of three paragraphs which best represented their relationships (Each paragraph demonstrated either a secure, anxious/ambivalent, or avoidant type). Bartholomew and colleagues worked to combine both socio-psychological and developmental attachment theories to understand attachment in adults. This was based on a combination of models that focus on the perception of the Self and that of others.

Security is defined as a Positive model of Self AND a Positive model of Others.  

>>>> Anxious/ambivalent (or preoccupied) is defined as Negative model of Self, combined with a Positive model of Others.

The Avoidant classification is split into two groups: Fearful and Dismissing.  

The Fearful group represents a Negative model of Self with a Negative model of Others.

The Dismissing group represents a Positive model of Self with a Negative model of Others.

To figure this out participants were given the Relationship Scales Questionnaire.

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If you’ve been following along with my other posts on Attachment you’ll recognize these group classifications. Stay tuned for tomorrows conclusion.