Comunicación serial asíncrona [11]

The research evidence pertaining to attachment status in adults with BPD will now be reviewed. Research evidence into attachment in people with BPD, is accumulating (for example Fonagy et al., 1996; Nickell, Wandby & Trull, 2002; Paris & Frank, 1989; Patrick et al., 1994; Sack, Sperling, Fagen & Foelsch, 1996; Sperling, Sharp & Fishier, 1991; Torgensen & Alnaes, 1992; West, Keller, Links & Patrick, 1993). Only selected studies will be presented.

Torgersen and Alnaes (1992) identified people with BPD using the Structured Interview for DSM III, SIDP. They used the PBI and found negative over­ involvement was the predominant child rearing style of parents of people with BPD.

Negative over-involvement can be seen as parents’ active hindrance of the child’s independence and separation, where the child’s natural curiosity tends to be met with warnings, hostility and an emphasis on potential danger (Parker et al., 1979, cited in Torgensen & Alnaes, 1992). In interpreting the results from this study, it is important to acknowledge that the PBI relies on patient’s retrospective memories, which may be subject to bias.

Using the AAI, Patrick et al. (1994) found all BPD patients were classified as ‘preoccupied’ in their attachment style and all fell into the sub category of ‘confused, fearful and overwhelmed in relation to their attachment figures’. Three quarters of the BPD patients in this study were classified as ‘unresolved, disorientated or disorganised’ with respect to loss, abuse and trauma. BPD diagnosis was also associated with reports of significantly lower maternal care and significantly higher maternal overprotection on the PBI compared to those patients diagnosed with dysthymia. This finding echoes Torgensen and Alnaes (1992) finding of the parental negative over-involvement child rearing style. Fonagy et al.’s (1996) study mirrored Patrick et al.’s findings in that 89% of participants with BPD were classified as ‘unresolved’ compared to 65% of those without a BPD diagnosis. Again, the classification of being ‘preoccupied’ was most frequently assigned to patients with BPD (75%), and within this category, the sub classification of ‘confused, fearful and overwhelmed’ was most common. This can be seen to relate to the unresolved trauma often inherent in the BPD patient’s life resulting from various forms of abuse particularly physical and sexual abuse (identified earlier as common risk factors for the disorder). Leading on from their findings, these authors propose that individuals with BPD are disorganised in their self-representation, partly as a result of their disorganised attachment styles.

In an attempt to control for Axis I disorders and the full range of non BPD Axis-II disorders, Nickell et al. (2002) explored parental bonding and attachment constructs in a non-clinical sample of young adults (18 year old students). They maintained that previous findings relating to parental bonding and attachment might have been a function of co-morbid psychopathology. Moreover, they recognised that previous studies had not controlled for childhood adversity. They used a variety of appropriate measures; the Structured Interview for DSM-IV Personality Disorders (SIDP-IV; Pfohl, Blum & Zimmerman, 1995), the Diagnostic Interview for Borderlines-revised (DIB-R; Gunderson & Zanarini, 1992) and the MMPI-Borderline Personality Disorder Scale (MMPI-BPD; Morey, Waugh & Blashfield, 1985) to assess features of BPD. The familial Experiences Interview (FEl; Ogata, 1988) was administered to identify childhood physical and sexual abuse. The PBI was administered to obtain data about relationships with parents. Following sophisticated hierarchical regression analyses, these authors found that even whilst controlling for both childhood adversity and Axis 1 and non BPD Axis 11 pathology, certain parental bonding and attachment patterns were significantly related to BPD features. Participants with BPD showed an anxious or ambivalent attachment pattern, and their perceptions of care were characterised by mothers as being less caring, more overprotective and more encouraging of independence. The focus on the mother’s parenting style specifically, is a relatively new finding, whereas until now parenting style in general was addressed. ‘Over-protectiveness’ and ‘encouraging of autonomy’ seem to indicate a paradox. ‘Autonomy encouraged by mother’ was explored further and subsequently redefined by the authors as an ‘over-permissiveness,’ which includes items such as ‘let me go out as often as 1 wanted’. This can be seen to relate to a lack of parental control. Nickell et al. (2002) go on to describe the combination of the aforementioned factors which constitute a conflicting and contradictory perception of one’s mother

which they relate to alternating images of the caregiver and the characteristic tendency for BPD patients to use ‘splitting’ as a mode of functioning. This psychoanalytical term refers to the tendency to separate the ‘object’ (attachment figure or other person) into a good and bad form. This happens so that the individual can avoid the conflict (anxiety evoked) between loving and hating the other, who in reality is both good and bad.

To summarise, BPD has been associated with an anxious-preoccupied attachment style and more specifically with ‘confused, fearful and overwhelmed’ as the most common sub-classification. It is thought that this classification characterises the BPD patients’ emotional template of intimacy and anger (Dutton, Saunders & Starzomski, 1994). The BPD diagnosis is also associated with being ‘unresolved, disoriented and confused regarding trauma and loss’. Specifically, perceived low maternal care, perceived high maternal over-protection and more recently, a maternal over­ permissiveness (an apparently contradictory parenting style), appears characteristic of mothers of people with BPD. Disorganised attachment style as described earlier, can be seen as a mixture of ‘avoidant’ and ‘anxious-ambivalent’ behaviours. As yet however, other than the frequently assigned ‘unresolved’ status finding, evidence for the disorganised attachment style in people with BPD has not as yet emerged.

(1.3) MENTALISING OR THEORY OF MIND (TOM)