Hypermentalizing in Borderline Personality Disorder: A Model and Data

Interpersonal difficulties are a widely accepted characteristic of borderline personality disorder (BPD). However, the results of empirical findings of deficits in social-cognitive abilities that may underlie interpersonal difficulties in this population have been mixed. In this paper, we review the literature on social-cognitive impairment in BPD by organizing studies based on patterns of positive and negative of findings. We provide a new model of mentalizing impairment in BPD by integrating findings into one framework that suggests hypermentalizing as the core feature of social-cognitive impairment in BPD. We review data in support of a hypermentalizing model of BPD and situate this data in the broader context of current work on hypermentalizing.     

Eating Disorders,Impaired Mentalization,and Attachment: Implications for Child and Adolescent Family Treatment

ABSTRACT

This article reviews the attachment and neuroscience model of Mentalization Based Treatment (MBT) (Allen, Fonagy, & Bateman, 2008) and its application for understanding and treating eating disorders (Skarderud & Fonagy, 2012). Mentalization, or mentalizing, refers to the capacity to apprehend one’s own and others’ behavior in terms of underlying mental states (needs, emotions, desires, beliefs, goals, reasons, and thoughts). Evidence from prospective studies suggests that insecure attachment and poor mentalizing difficulties may be risk factors for the development of eating pathology (Jewell et al., 2015; Rothschild-Yakar, Levy-Shiff, Fridman-Balaban, Gur, & Stein, 2010; Rothschild-Yakar & Stein, 2013). Preliminary research on the use of MBT for treating eating disorders, with nonsuicidal self-injury co-morbidity, suggests some promise for this model (Robinson et al., 2015). The theoretical rationale and key interventions of the MBT eating disorder model (MBT-ED) used in a multicenter research and treatment project are discussed (Skarderud & Fonagy, 2012; Robinson et al., 2015). Modifications of MBT-ED’s structure and techniques are proposed for family treatment of adolescent and child patients with eating disorders. Case example illustrates the impact of problems in the family system with mentalizing capacities on family cohesion, the therapeutic process, and the family’s ability to help the child recover.     

Borderline personality disorder,complex trauma,and problems with self and identity: A social-communicative approach

Borderline personality disorder (BPD) is a relatively highly prevalent psychiatric disorder that is associated with very high personal and socioeconomic costs. This paper provides a state-of-the-art review of the relationship between complex trauma and key features of BPD, with a focus on problems with self-coherence and self-continuity. We first review evidence for the high prevalence of complex trauma in BPD patients. This is followed by a discussion of emerging knowledge concerning the biobehavioral mechanisms involved in problems related to self and identity in BPD. We emphasize three biobehavioral systems that are affected by complex trauma and are centrally implicated in identify diffusion in BPD: the attachment system, mentalizing or social cognition, and the capacity for epistemic trust—that is, an openness to the reception of social communication that is personally relevant and of generalizable significance. We formulate a new approach to personality and severe personality disorders, and to problems with self and identity in these disorders, rooted in a social-communicative understanding of the foundations of selfhood. We also discuss how extant evidence-based treatments address the above-mentioned biobehavioral systems involved in identity diffusion in BPD and related disorders, and the supporting evidence. We close the paper with recommendations for future research.     

Development of Borderline Personality Disorder in Adolescence and Young Adulthood: Introduction to the Special Section

Recognizable symptoms and features of borderline personality disorder (BPD) appear during adolescence. However, there has been resistance to diagnose or research this disorder prior to adulthood because of clinical lore that BPD is a long-standing illness and that personality traits are not stable until adulthood. This has resulted in little information regarding the development of and risk factors for BPD in youth. The goal of this special section is to examine the development of BPD in adolescence and young adulthood using a broad collection of approaches, including a theoretical review paper, two prospective studies, and a multi-method cross-sectional study. This body of work provides new insights into vulnerabilities that may transact with early attachment relationships and experiences to predict the emergence of BPD in adolescence and young adulthood. These papers also point to future research that is needed to better understand the etiology, development, and course of BPD.     

The Application of Attachment Theory and Mentalization in Complex Tertiary Structural Dissociation: A Case Study

The concept of structural dissociation can provide useful information for increasingly complex applications of mentalizing in therapeutic settings; however, little integration of the two approaches has emerged. Grounded in the intricate case of a woman diagnosed with dissociative identity disorder, this case study integrates and applies the concepts of structural dissociation and mentalizing from an attachment perspective. Client history includes pervasive spiritual and sexual abuse, as well as extreme neglect throughout her development. The presenting problems, relevant history (including the profound impact of neglect), and the therapeutic models that guided treatment are described. Also presented are the specific therapeutic interventions that have facilitated and strengthened therapeutic alliances, levels of integration, and mentalizing capacity in this challenging but rewarding study of human resiliency.     

Mentalizing Family Violence Part 1: Conceptual Framework

This is the first of two companion papers describing concepts and techniques of a mentalization‐based approach to understanding and managing family violence. We review evidence that attachment difficulties, sudden high levels of arousal, and poor affect control contribute to a loss of mentalizing capacity, which, in turn, undermines social learning and can favor the transgenerational transmission of violent interaction patterns. It is suggested that physically violent acts are only possible if mentalizing is temporarily inhibited or decoupled. However, being mentalized in the context of attachment relationships in the family generates epistemic trust within the family unit and reduces the likelihood of family violence. The implications of this framework for therapeutic work with families are discussed.     

Attachment, borderline personality, and romantic relationship dysfunction

Previous studies have implicated attachment and disturbances in romantic relationships as important indicators for Borderline Personality Disorder (BPD). The current research extends our current knowledge by examining the specific associations among attachment, romantic relationship dysfunction, and BPD, above and beyond the contribution of emotional distress and nonromantic interpersonal functioning in two distinct samples. Study 1 comprised a community sample of women (N = 58) aged 25-36. Study 2 consisted of a psychiatric sample (N = 138) aged 21-60. Results from both Study 1 and Study 2 demonstrated that (1) attachment was specifically related to BPD symptoms and romantic dysfunction, (2) BPD symptoms were specifically associated with romantic dysfunction, and (3) the association between attachment and romantic dysfunction was statistically mediated by BPD symptoms. The findings support specific associations among attachment, BPD symptoms, and romantic dysfunction.     

Autistic traits in mentalization-based treatment for concurrent borderline personality disorder and substance use disorder: Secondary analyses of a randomized controlled feasibility study

Autism is suggested to be a dimensional construct and often represents a comorbid state. However, research on the clinical implications of the presence of autistic traits is scarce. This study aimed to investigate the impact of subclinical autistic traits in mentalization-based treatment (MBT) for concurrent borderline personality disorder (BPD) and substance use disorder (SUD). Based on the data of a randomized controlled feasibility study by Philips, Wennberg, Konradsson, and Franck (2018), secondary analyses were conducted. It was tested, if patients’ (N = 46) levels of autistic traits were associated with treatment outcome measured in the course of and after treatment using interviews and self-report measures. Participants’ autistic traits were not associated with the change in the severity of BPD throughout and at the end of the treatment. However, results showed associations between autistic traits and the change in patients’ consumption of alcohol in the course of MBT. Furthermore, there was an association between autistic traits and the change in mentalizing capacity at the end of MBT, indicating that elevated autistic traits were associated with an improvement in mentalizing capacity. Autistic traits on a subclinical level do not appear to be a complicating factor in MBT for concurrent BPD and SUD. On the contrary, in terms of mentalizing capacity autistic traits might be associated with a larger potential for improvement or facilitate treatment outcome. Further research is needed to explore the role of higher autistic traits in treatment of this special patient group.     

Seeking Security in the Face of Fear: The Disorganized Dilemma

Attachment theory has been instrumental in identifying insecure disorganized attachment as a developmental pathway that leads to severe psychopathology in adults. Psychotherapy with these patients is challenging, offering a confusing pattern of relatedness, difficulties in mentalizing, problems expressing affect, utilizing dissociative defenses, and trying to gain an understanding of their subjectivity. This article provides a theoretical overview of disorganized attachment focusing on its etiology and how it presents throughout the life span. It reviews important therapeutic guidelines that help navigate the relationship with adults and presents a case study highlighting some clinical challenges.     

Examining the impact of salesperson interpersonal mentalizing skills on performance: the role of attachment anxiety and subjective happiness

Due to the dynamic and interpersonal nature of selling, understanding affective and cognitive relationships and their influence on performance has gained the attention of sales scholars. Moreover, recent literature has created opportunities to study the impact of cognitions, such as salesperson theory-of-mind, on sales performance. This research develops a model involving salesperson interpersonal mentalizing skills (i.e. rapport building, detecting nonverbal cues, taking a bird’s-eye view, shaping the interactions), subjective happiness, attachment anxiety, and sales performance. Although salesforce optimization is critical in any economy, emerging economies are the growth frontier for many global companies. Using three samples from Brazil, we investigate the telecom, banking, and retail industries, providing generalizable results from one such emerging economy. We find that, in general, it is the influence of attachment anxiety and subjective happiness on interpersonal mentalizing skills which ultimately impacts sales performance. Based on these findings, we discuss several theoretical and managerial implications.     

Transference Focused Psychotherapy for Patients with Comorbid Narcissistic and Borderline Personality Disorder

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experience with and research data on patients with comorbid narcissistic personality disorder/borderline personality disorder (NPD/BPD). We briefly review object relations formulations of severe narcissistic pathology, as well as recent research in attachment and the allied concept of mentalization, which have provided a new lens through which to view narcissistic disorders. The research findings from two randomized clinical trials demonstrating the efficacy and effectiveness of TFP are presented. The data from the two Randomized Clinical Trials (RCT) allowed for the study of the characteristics of the subgroup of borderline personality disorder patients who have comorbid NPD/BPD. Findings on comorbidity, attachment status, capacity for mentalization, and level of personality organization of borderline patients with comorbid NPD/BPD, compared with borderline patients without comorbid narcissistic pathology (BPD), are presented. Clinical implications of the observed group differences are discussed, with a focus on refinements in the technique of TFP. Clinical case material is presented to illustrate the specific challenges posed by narcissistic patients to carrying out TFP in each phase of treatment.     

Mutual Regulation,Mentalization, and Therapeutic Action: A Reflection on the Contributions of Ed Tronick to Developmental and Psychotherapeutic Thinking

This article celebrates Ed Tronick’s contribution to psychodynamic developmental psychology. Tronick’s ideas have implicitly and explicitly influenced late 20th-century and early 21st-century psychoanalytic thinking, and his contribution is here acknowledged in relation to the work on the developmental ideas concerning mentalizing. Tronick’s (1989, 2007) mutual regulation model (MRM) is outlined and examined from the point of view of the attachment-theory-based mentalization model of interpersonal interaction and psychopathology. The article identifies common ground between clinical implications of Tronick’s MRM and the mentalization model as independent but complementary ways of expanding ideas originating in attachment theory, and highlights ways in which the MRM provides greater clarity for several concepts which are frequently used in writings about mentalizing such as the background of safety and the holding environment.     

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

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

Social perspective coordination in youth with borderline personality pathology

This study investigated social perspective coordination (SPC) in youth (15-24-year-olds) with first-presentation borderline personality disorder (BPD). SPC is defined as the capacity to differentiate and integrate the perspective of the self with the perspectives of others (Selman, Beardslee, Schultz, Krupa, & Podorefsky, 1986). Two groups: patients with full or sub-syndromal BPD (n = 30) and patients with major depressive disorder (MDD; n = 30) completed measures of SPC derived from the interpersonal negotiation strategies (INS) model (Selman et al., 1986). Compared with the MDD group, the BPD group responded to all vignettes with significantly lower SPC scores and SPC was a significant predictor of BPD status over and above self-reported, personality factors (Neuroticism and Agreeableness), attachment disturbance and functional impairment. These findings suggest that disturbances in social cognition are an important characteristic of individuals with BPD pathology. These difficulties extended beyond attachment contexts and were not limited to situations involving BPD-related themes of abandonment, deprivations or mistrust/abuse.     

Attachment in Adolescence and Borderline Personality Disorder

Borderline personality disorder (BPD) has been conceptualized as a constellation of symptoms related to problems in self-functioning, emotion regulation, and interpersonal relationships. Its etiology has been connected to individuals’ early childhood environment, caregiving relationships, and traumatic life events. Recent literature has noted the potential presence of BPD beginning in adolescence, or even earlier in childhood. Attachment theory offers a lens for understanding the symptoms of borderline personality disorder and identifying potential aspects of treatment that may be specifically valuable for adolescent patients. Adolescence marks a time when the attachment system has increased relevance due to the importance of identity formation, peer relationships, body representations and the development of autonomy at this time, in the face of physical changes and academic challenges. This article will summarize research on attachment, body representations, personality disorders, and features of development in adolescence, in order to enhance clinical understanding of patients who presenting with these types of difficulties.     

The importance of parental verbal and embodied mentalizing in shaping parental experiences of stress and coparenting

Parental mentalizing—recognizing that children are separate psychological entities, who have their own thoughts, wishes, and intentions that motivate their behaviors—is traditionally considered a verbal, linguistic capacity. This paper aimed to examine the relation between parental verbal mentalizing (parental reflective function; PRF) and its nonverbal form—parental embodied mentalizing (PEM)—and how both constructs contribute to parents’ subjective experience of parenting, namely parental stress and coparental alliance. 68 mothers and their three-months-old babies were observed to assess PEM, interviewed to code PRF, and completed self-reports of coparental alliance and parental stress. PEM was found to be positively correlated with PRF. Mediation analyses revealed that higher PEM, but not PRF, was associated with lower parental stress, mediated by positive reports of coparental alliance. The findings support adopting a multifaceted approach when studying parental mentalizing, both in terms of assessing parental mentalizing beyond its verbal expressions to include also embodied aspects, as well as investigating its impact beyond infant development to include the familial context within it operates. Conceptual, empirical and clinical implications are discussed.     

Mentalisierungsbasierte Psychotherapie bei schizophrenen Psychosen

Recently, there has been growing interest in new methods of psychotherapeutic interventions for schizophrenic patients. Social cognition, social functioning and quality of life are central objectives. Mentalization-based therapy (MBT) is a specific psychodynamic method developed from the fundament of attachment theory and empirical psychotherapy research for the treatment of borderline personality disorder, particularly focusing on attachment relationships, mentalizing capacity and affect regulation. Studies have shown that MBT is able to ameliorate interpersonal experience and social life. The latest neuroscientific findings support this view and encourage the application of a modified form of MBT in the treatment of schizophrenic patients. The authors present a concept for disorder-specific interventions in schizophrenia, including psychoeducational aspects and mentalizing exercises which step-by-step lead to a more reflective work in mentalization-based group psychotherapy.     

Children At-Risk for Borderline Personality Disorder

Adult patients who have been diagnosed with borderline personality disorder (BPD) have provided valuable information about events and family dynamics that are frequently associated with BPD. Clinicians who work with children are frequently aware of family or individual characteristics that may put a child at risk for developing BPD. Such situations frequently involve attachment issues with the child's caregivers and can include sexual abuse, divorce, alcoholism/substance use, illness/ death, and neglect. Child characteristics such as learning difficulties and temperament may also predict BPD. Yet, many children are resilient and seemingly unaffected by these events or situations, especially when early intervention may prevent development of BPD.     

Sensory sensitivity, attachment experiences, and rejection responses among adults with borderline and avoidant features

Both avoidant and borderline personality disorder (APD and BPD) are theoretically associated with temperamental vulnerabilities, adverse attachment experiences, and negative (pessimistic or catastrophic) reactions to the threat of perceived rejection; however, more work is needed to differentiate how these processes account for the etiology and maintenance of both disorders. In this study, 156 adults completed questionnaires measuring APD and BPD features, temperament (sensory-processing sensitivity), mood, and attachment experiences. A vignette task was devised to examine pessimistic cognitive-affective reactions in situations signaling potential rejection. Both APD and BPD were associated with temperamental sensitivity, but BPD was uniquely linked with a subscale measuring sensitivity to mental and emotive stimuli, whereas APD was uniquely linked with a subscale measuring the control and avoidance of aversive stimulation. Compared to APD, BPD was more strongly linked with negative moods (anxiety, anger, sadness) and insecure attachment to parents, whereas APD was more strongly linked (than BPD) to pessimistic cognitive-affective responses to rejection-related situations.     

The nature of borderline personality disorder: multiple dimensions, multiple symptoms, but one category

Borderline personality disorder (BPD) is a multidimensional syndrome that is not rooted in a single diathesis. Each of its features (affective instability, impulsivity, unstable relationships, and cognitive defects) reflects different diatheses. BPD differs from other Axis II disorders in its high level of symptoms, but is not a variant of an Axis I disorder and is difficult to describe through dimensional traits. This review suggests that BPD needs to be diagnosed with a narrower set of criteria that cover all of its domains. In the long run, the disorder will need to be redefined on the basis of its etiology and pathogenesis.