Professional Documents
Culture Documents
Attachment and Borderline Personality Disorder
Attachment and Borderline Personality Disorder
P e r s o n a l i t y D i s o rd e r
a, b
Anna Buchheim, PhD *, Diana Diamond, PhD
KEYWORDS
Attachment representation Unresolved trauma Reflective functioning Oxytocin
Transference focused psychotherapy
KEY POINTS
Borderline personality disorder has been associated with increased occurrence of inse-
cure and especially unresolved attachment representations.
Unresolved attachment has been linked to impaired cognitive functioning, trauma-related
psychopathology, an impaired oxytocin system, and higher neural activations in the limbic
system.
Two randomized clinical trials on transference-focused psychotherapy have assessed
attachment representations of patients with borderline personality disorder and how
they change over the course of transference-focused psychotherapy.
Results demonstrated that transference-focused psychotherapy was superior in showing
significant improvements in attachment representations and reflective functioning
compared with other treatments.
A significant shift from unresolved to organized attachment suggests that transference-
focused psychotherapy can be considered an effective treatment for traumatized
patients.
The authors do not have any relationship with a commercial company that has a direct finan-
cial interest in the subject matter or materials discussed in article or with a company making a
competing product.
a
Institute of Psychology, University of Innsbruck, Innrain 52, Innsbruck 6020, Austria; b City
University of New York, Personality Disorders Institute, Weill Medical Center of Cornell Uni-
versity, New York University, New York, NY, USA
* Corresponding author.
E-mail address: anna.buchheim@uibk.ac.at
Abbreviations
AAI Adult Attachment Interview
AAP Adult Attachment Projective Picture System
BPD Borderline personality disorder
DBT Dialectical behavior therapy
ECP Experienced community psychotherapists
OT Oxytocin
RCT Randomized clinical trial
RF Reflective functioning
TFP Transference-focused psychotherapy
internalized representations of self and significant others that are highly polarized and
affectively charged. These distorted perceptions of self and others are thought to
contribute to disturbed interpersonal relationships and identity diffusion experienced
by patients with BPD. The emerging consensus that the essential features of person-
ality disorder involve difficulties with self-identity and interpersonal functioning4,5 has
long been a central tenet of object relations theory2 and is now reflected in Diagnostic
and Statistical Manual of Mental Disorders-5, section III.6 Personality researchers and
clinicians across diverse treatment orientations link self and interpersonal functioning
to mental representations, for example, to schemata or internal working models of
attachment.7
Attachment theory provides a powerful framework for understanding the links be-
tween close relationships, mental representations of attachment, and psychopathol-
ogy and its neural correlates, and has widened and sharpened the lens through
which we view personality development in general and personality disorders specif-
ically.8–13 The concept of adult attachment status covers a specific aspect of person-
ality and measures an individual’s current representational state with respect to early
attachment relationships and their associated modes of defenses and affect regula-
tion. In this article, we review the major contributions of attachment theory and
research to understanding personality disorders, first introducing the research instru-
ments that have been developed to assess mental representations of attachment in
adults. Second, we present a model of BPD that integrates both attachment and neu-
ral correlates, with a focus on the significance of the lack of resolution of loss and
trauma in individuals with BPD. Finally, we discuss the findings from several random-
ized clinical trials (RCTs) that have been used to assess attachment representations in
patients with BPD, providing data on individual patients that demonstrates the nature
and quality of the maladaptive attachment representations in this group.
attachment relevant questions with concrete probes designed to elicit episodic mem-
ories (the AAI) or stories to attachment-related pictures (the AAP).
The AAI is a semistructured interview designed to elicit thoughts, feelings, and
memories about early attachment experiences and to assess the individual’s state
of mind with respect to early attachment. Main and Goldwyn (Main M, Goldwyn R.
Adult attachment scoring and classification system, Version 6.0. University of Califor-
nia at Berkeley: Unpublished manuscript; 1998) identified 3 major organized patterns
of adult attachment:
Secure/autonomous, characterized by open, seemingly honest, coherent
discourse that gives the impression that individuals value the significance of
attachment relationships;
Dismissing, characterized by a constricted and distant discourse style in which
all relationships are either idealized or devalued; and
Preoccupied, characterized by a confused, angry, or passive discourse style that
suggests that individuals are entangled in these relationships.
The 2 disorganized patterns include the unresolved attachment status and cannot
classify category.
The unresolved category is characterized by a global breakdown in discourse
strategy around themes of loss or trauma
The cannot classify category is characterized by a lack of any consistent
discourse style, or by 2 distinct but diverse patterns.18
The AAP16,17 provides attachment classifications based on the analysis of “story” re-
sponses to a set of theoretically derived attachment-related drawings of scenes depict-
ing solitude, illness, separation, death, and potential maltreatment. Story coding reflects
the evaluation of story content, defensive processes, and the inclusion of personal
experience. Story content is evaluated to which there are integrated representations
of self and attachment figure, and the degree to which narrative show an integration
of the responsivity and sensitivity of self and other. The AAP narratives are evaluated us-
ing 2 dimensions: Agency of self, defined as the capacity for constructive thinking or ac-
tion, and Connectedness, defined as the desire to be connected in close relationships.
Attachment classifications in the AAP are derived from the analysis of attachment
narratives with 3 organized categories (secure, dismissing, preoccupied) and 1 unre-
solved status with respect to trauma, loss, or attachment-related threats. Individuals,
who are unresolved regarding experiences of loss or trauma, report in their narratives
content or process markers of unintegrated, traumatic, or threatening story character-
istics. These individuals, overwhelmed by trauma or loss, may therefore become dys-
regulated during the attachment task. Dysregulation can be momentary or prolonged,
but in either case the individual is unable to use defensive processes to remain orga-
nized and to exclude distressing thoughts and feelings from consciousness.17
With respect to borderline pathology, all studies using interview measures (Main M,
Goldwyn R. Adult attachment scoring and classification system, Version 6.0.
University of California at Berkeley: Unpublished manuscript; 1998)18,19 reported a
strong association between BPD and indices of unresolved attachment.9,10,12,19–23
Similarly, approximately one-half of the attachment-style studies, which use self-
report measures, reported a strong association between BPD and indices of fearful
or preoccupied and angry/hostile attachment.24,25
Insecure/disorganized attachment patterns impart greater risk for the maladaptive
personality traits underlying BPD,26 although a range of insecure states of mind
have been linked to BPD.22 However, there is increasing evidence that patients with
654 Buchheim & Diamond
BPD, particularly those who have been hospitalized and/or are suicidal and/or chron-
ically self-injurious (parasuicidal), have failed to integrate or resolved attachment trau-
mata, particularly sexual and physical abuse by caretakers.23,27,28 In several studies,
BPD has been associated with an increased occurrence of insecure and especially
disorganized/unresolved attachment representations.9,10,12,20,21,29
Hence, particularly important for understanding attachment in clinical groups is the
distinction between secure versus insecure and organized versus disorganized
attachment states of mind. Those with disorganized attachment (either unresolved
or cannot classify) tend show multiple, unintegrated, and contradictory states of
mind with respect to attachment, and thus not surprisingly are more highly repre-
sented in clinical groups and particularly in those with personality disorders. It should
be noted that in the 2 RCTs on transference-focused psychotherapy (TFP), more than
one-half the patients had a primary attachment classification of disorganized. In the
US Weill Cornell RCT that included patients with borderline and some narcissistic dis-
orders, 31.7% of patients with BPD were classified as unresolved with respect to
attachment and 18.3% were classified in the cannot classify category, with 30% of pa-
tients classified as dismissing with respect to attachment and 15% of patients were
classified as preoccupied.10,22
a life history of early maltreatment.37 Decades of research have shown that early ex-
periences of maltreatment, such as sexual and physical abuse and emotional neglect,
are implicated in the etiology of BPD.25,38–40 There is also increasing evidence that the
oxytocinergic system may be involved in these domains of dysfunction and may, thus,
contribute to borderline psychopathology.35 The association of interpersonal hyper-
sensitivity and history of early maltreatment were supported by data showing lower
OT concentrations in individuals with BPD with insecure/unresolved attachment or a
history of early traumatization.32,41,42
A recent study using the AAP explored the neural correlates of emotional dysregu-
lation during the activation of the attachment system in patients with BPD compared
with healthy controls using functional MRI.20 Unresolved attachment was associated
with increasing amygdala activation over the course of the attachment task in patients
as well as controls. Unresolved controls, but not patients, showed activation in the
right dorsolateral prefrontal cortex and the rostral cingulate zone. The authors inter-
preted this as a neural signature of the inability patients with BPD to exert top-down
control under conditions of attachment distress. These findings pointed to neural
mechanisms for underlying affective dysregulation in BPD in the context of attachment
trauma and fear.20,35
deficits in the ability to perceived and interpret human behavior in terms of intentional
mental states.48 Deficits in mentalization in turn lead to emotional dysregulation,
further disrupting the ability to mentalize.49 Difficulties with mentalization are related
to a history of unresolved attachment, which also leads to problems with affect regu-
lation, attention, and self-control.50
Fonagy and colleagues (Fonagy P, Target M, Steele H, et al. Reflective51 functioning
manual: version 5, for application to adult attachment interviews. Unpublished manu-
script; 1998) established the concept of mentalization or reflective functioning (RF) on
the basis of the AAI transcripts, having developed the idea that the interviewees
showed different forms and levels of thinking about mental states such as thoughts,
feelings, desires, and beliefs as underlying one’s own and others’ behaviors. Mental-
ization has been shown to be severely impaired in patients with BPD.22,52 Recent
studies examined the interplay of attachment and RF in patients with BPD and confirm
the theoretic assumption that RF mediates the relationship between attachment dis-
turbances and BPD symptom severity.13,53 Both attachment representation and men-
talization (RF) have been used as moderator, mediator, and outcome variables in
psychotherapy studies.13,24,54,55
The RF Scale (Fonagy P, Target M, Steele H, et al. Reflective functioning manual:
version 5, for application to adult attachment interviews. Unpublished manuscript;
1998). Deficits in mentalization are assessed through the RF scale and Fonagy devel-
oped the RF scale to capture “the psychological processes underlying the capacity to
mentalize” in the context of attachment relationships. Designed for use with the AAI,
the RF scale is an 11-point scale that assesses individual differences in the capacity to
mentalize. Mentalization in the RF system includes a number of dimensions, including
that mental states have a developmental trajectory and may shift and change with
maturation, are subject to change with change in life circumstances or relationships,
and are relatively opaque and subject to limitations, including on the part of the inter-
viewer who may not intuit or understanding the formulations of the speaker or have
discrepant views of things. The RF scale ranges from 1 (negative RF, in which inter-
views are antireflective, totally barren of mentalization, or grossly distorting of the
mental states of self and others) to 9 (exceptional RF in which interviews show unusu-
ally complex, elaborate, or original reasoning about mental states). Those with person-
ality disorders typically score at level 3 or below that is characterized by a simplistic,
naı̈ve, and formulated view of mental states or by hyperactive or over analytical RF, in
which the individual claims infallible knowledge of mental states with little evidence to
corroborate this conviction and lack of awareness of the separateness of mind of self
and others (Fonagy P, Target M, Steele H, et al. Reflective functioning manual: version
5, for application to adult attachment interviews. Unpublished manuscript; 1998).
Using the RF scale, an accretion of studies has now linked the deficits in mentaliza-
tion to the development of personality disorders. Individuals with a history of abuse are
less likely to develop BPD if they had high RF on the AAI, (Fonagy P, Target M, Steele
H, et al. Reflective functioning manual: version 5, for application to AAIs. Unpublished
manuscript; 1998), although the capacity for RF may moderate the negative impact of
a traumatic early attachment history and potentially guard against the transgenera-
tional transmission of insecure disorganized attachment patterns. Slade56 has sug-
gested that RF may be “the core capacity” that differentiates secure from insecure
states of mind and that attachment categories may “be proxies” for an underlying
organizing psychological capacity of mentalization. Just as deficits in mentalization
are fundamental to severe personality disorders, several studies have shown that im-
provements in mentalization are a key mechanism of change in psychodynamic psy-
chotherapy with such patients.22,43,52
Attachment and Borderline Personality Disorder 657
In sum, patients with BPD with unresolved attachment are significantly more
impaired with respect to psychopathology, psychosocial functioning, and neuropep-
tide modulation and have reported not necessarily more attachment trauma in their
history, but rather a lack of resolution of traumatic loss and abuse. Moreover, unre-
solved attachment is associated with a variety of neural and social cognitive correlates
that mediate the affective dysregulation. Taken together this suggests that low RF and
insecure, unresolved attachment are important targets of change in psychotherapy.
the effectiveness and efficacy of TFP for borderline pathologies. A full description of
the method and findings from the 2 RCTs can be found elsewhere.10,22,52,63,64 In
this summary, we focus on the changes in from insecure to secure attachment and
mentalization observed in both studies, with a particular focus on the shift from disor-
ganized to organized attachment status after 1 year of TFP that was observed only in
the Vienna-Munich study. The latter study is described in greater detail with case ma-
terial presented to illustrate these changes.
In this study by Buchheim and colleagues,10 92 patients were administered the AAI
at the beginning and 63 after 1 year of treatment, The AAI interviews were tran-
scribed verbatim and scored by 2 certified raters, blind to time and treatment condi-
tion, scored the transcripts to assign the individual to 1 of 4 attachment
classifications: secure/autonomous, dismissing, preoccupied, and unresolved. A
subset of transcripts (n 5 36) was double rated by both judges showing agreement
on 89% of the 4 categorical classifications (kappa 5 0.84), and on 94% of the 2 clas-
sifications (organized vs unresolved; kappa 5 0.89). Moreover, Buchheim and col-
leagues10 focused on the coherence continuous subscale (range, 1–9). The AAI
was additionally scored with the RF Scale (Fonagy P, Target M, Steele H, et al.
Reflective functioning manual: version 5, for application to adult attachment inter-
views. Unpublished manuscript; 1998). Coders for the RF scale were trained at the
Anna Freud Center in London. Coders were blind to treatment condition. The 2
coders coded a subset of each other’s transcripts (n 5 25) and showed a good inter-
rater reliability (k 5 0.79).
Data on Reflective Functioning
Analyzing RF, there were no differences between the groups with regard to socio-
demographic and clinical variables at baseline.52 Baseline RF was 2.77 (standard
deviation, 1.27) in the TFP and 2.66 (standard deviation, 0.93) in the ECP group.
TFP group improved significantly with regard to RF (effect size d 5 0.34), whereas
the ECP group remained unchanged (d 5 0.07).52 RF at baseline was about 2.7 with
no difference between the 2 groups. This result confirmed former studies reporting
questionable or low mentalizing capacity in patients with BPD.67 A score of 3 is
characterized by either naı̈ve/simplistic or overanalytic/hyperactive reflections on
the mental states of self and others (Fonagy P, Target M, Steele H, et al. Reflecting
functioning manual: version 5, for application to adult attachment interviews.
Unpublished manuscript; 1998). The findings52 revealed significant within-group
differences of RF in the TFP group, although no changes occurred in the ECP
group.
Why do you think your parents behaved as they did during your childhood?
Because my mother loved me more than anything, that’s why.
This statement is characterized by self-serving, coded as an RF of 1, a very low RF.
And my father? Well, I don’t really know why my father was so brutal. Well, he grew up
without a father. His father was an alcoholic too, so could this have influenced him? But
why he was more friendly toward me than to the others, the other children, I don’t really
know.
This statement is characterized by disavowal, coded as an RF of 1, a very low RF.
660 Buchheim & Diamond
Case Example of Reflective Functioning with the Same Patient After 1 Year of
Transference-Focused Psychotherapy Treatment
Why do you think your parents behaved as they did during your childhood?
Well, I think my father was so aggressive because, I think that maybe this is also in the
family, his father was an alcoholic, too, and was so aggressive and apparently his mother
was also aggressive toward him and hit him, and, but I also think that my father was
desperate some way, because he had imagined his life to be different, I think, than to be
sitting in a small apartment with 3 children.
And why my mother, ok, she had 3 children to take care of and she was dependent on, at
that time, the husband bringing home the money. I think that my mother was so, well, busy
with herself, with her illnesses and all that, that she could not bear it at all that I was feeling
unwell.
This statement is characterized by an accurate if ordinary attribution of mental states, coded as
an RF of 5, or ordinary RF.
This shift from low to moderate RF in the study by Fischer-Kern and colleagues52 was
in line with the New York-Cornell RCT, which yielded a significant increase of RF only
in TFP, but not in dialectic behavior therapy and psychodynamic supportive therapy.22
Based on Kernberg’s2 developmentally based theory of BPD, the central
mechanisms of change in TFP stem from the integration of polarized affect states
and split-off mental representations of self and others, which gradually enables the
patient to think more coherently and reflectively. Several studies on process and
outcome in psychodynamic therapies have shown enhancement in RF as a long-
term goal. A study on psychodynamic, hospitalization-based treatment for patients
with personality disorder revealed no increases in RF during 1 year of treatment68
and 2 single case studies revealed improvements of RF only after 5 years of outpa-
tient psychodynamic treatment.69,70 Therefore, the findings that show improve-
ment in RF in patients with BPD after 1 year of TFP are particularly impressive.
The study by Fischer-Kern and colleagues,52 coupled with the work of Levy and
colleagues22 (2006) has shown that TFP is not only efficacious as a treatment for
BPD with respect to symptom change but also with regard to improvements in
mentalization, and as illustrated in the following section in improvements in the se-
curity of attachment representations.
I’d like you to try to describe your relationship with your parents as a young child if you could
start from as far back as you can remember?
I was abused by my father when I was 6 years old, I think until I was 10 years old. I told once my
mother and she terribly rejected me. (Pause) I think it was not too dramatic anyway that time, I
think I was provoking it somehow. I always tried to keep it away from me for a long time,
maybe it would be better to be a boy, I really don’t know.
This statement represents an unresolved state of mind based on evaluations of the
interviewee’s transient mental disorientation when describing experiences of sexual abuse.
This discourse pattern suggests that these experiences are accessible to memory, but not yet
integrated to create a whole sense of self–other representation. In this example, we can
identify descriptions containing irrational convictions of the interviewee’s own guilt and
confusion between self and other (Main M, Goldwyn R. Adult attachment scoring and
classification system, Version 6.0. University of California at Berkeley: Unpublished manuscript;
1998). In sum, the existence of unprocessed traumas is evident in the discourse characteristics
communicated in the structure of the language, even when they are not verbalized directly,
but just alluded to in the content, alerting the therapist to their existence.
The numbers of patients in the study10 who improved versus worsened in their
secure (F) or insecure (Ds 1 E 1 U) attachment status were compared by the exact
McNemar test. No significant improvements in attachment representations were
found within the ECP group. On the contrary, highly significant improvements
were found within the TFP group (exact McNemar test; P < .001). Comparing
both groups, the proportion of TFP patients (12 of 38) who improved in their attach-
ment security was significantly higher than the proportion (0 of 25) in the ECP group
(Fisher exact test; P 5 .002). Fully analogous results were obtained for the changes
between the organized (F 1 Ds 1 E) and disorganized/unresolved (U) status. No
significant shifts from disorganized to organized were found within the ECP group,
although significant shifts from disorganized to organized were found within the
TFP group (exact McNemar test; P < .001). Comparing both groups, the proportion
of patients with improved organization (17 of 38) was significantly higher in the TFP
group than that of the patients in the ECP group (3 of 25; Fisher exact test;
P 5 .012).10
Case Example of Unresolved Attachment with the Same Patient After 1 Year of
Transference-Focused Psychotherapy Treatment
I’d like you to try to describe your relationship with your parents as a young child if you could
start from as far back as you can remember?
I was abused by my father when I was 6 years old, I think until 10 years. Now I realize how much
that affected me, especially that I was not able to talk to my mother about it. She denied it and I
did also. It is still very hard to talk about it. And I still have sometimes troubles not to accuse
myself, but I know better now, that it was possibly not my fault.
This statement demonstrates that the patient does not deny the abusive experiences anymore
and is able to reflect in a coherent manner how hurtful it was to grow up with a mother, who
was not able to protect her.
662 Buchheim & Diamond
Consistent with the findings described previously for the Cornell-NY RCT, the
improvement of coherence was considerably higher in the TFP group (Cohen’s
d 5 1.27) than in the ECP group (d 5 0.32).10
In sum, as expected, attachment status did not differ between the 2 patients groups
at baseline, showing a predominance of unresolved attachment representations. This
result confirmed previous studies on attachment in BDP9,21,29,71 and various psycho-
logical models agree on childhood traumatization as one risk factor for the develop-
ment of BPD.40 Moreover, the study by Buchheim and colleagues10 found that
unresolved patients with BPD were significantly more impaired with respect to psycho-
pathology and psychosocial functioning, and have reported greater levels of traumatic
abuse and loss in their history, suggesting that unresolved attachment might constitute
an aggravating factor in BPD and thus an important target of change in psychotherapy.
These findings revealed significant within-group changes of attachment status (inse-
cure to secure and unresolved to organized) in the TFP group, although no significant
changes occurred in the ECP group. This finding was in line with a former study yielding
a significant increase of attachment security only in TFP, but not in DBT and psycho-
dynamic supportive therapy.22 This study confirmed that improvements in borderline
symptomatology accompany improvement in attachment representations and a signif-
icant increase of coherence and RF in the patients’ narratives treated with TFP. The sig-
nificant shift from insecure to a secure attachment status in many of patients with BPD
in the TFP treatment group implied that TFP treatment was able to enhance the pa-
tients’ capacity to internalize a secure base, attachment related autonomy and capac-
ity for flexible integration. Adding to the findings of Levy and colleagues,22 Buchheim
and colleagues10 found a significant shift from unresolved to organized attachment
representations in the TFP group, suggesting that TFP can be considered an effective
treatment for traumatized patients. In TFP, the actual genetic origins of traumatic expe-
rience are less significant and usually not taken up and explored until later in the treat-
ment. Rather, the focus is on how trauma is embedded in the interplay of self–other
dyads (eg, victim, victimizer or sufferer/savior), and modes of defense and affect regu-
lation as they are activated in the therapeutic arena.72 During the first year of treatment,
TFP is designed to diminish self-destructive behaviors by clarifying the dual experience
of self as victim and victimizer through the here-and-now transference relationship.
These findings are consistent with the putative mechanisms of change in TFP, which
are assumed to result from the integration of polarized affect states and representa-
tions of self and other into a more coherent whole.13,63 Moreover, a greater number
of patients who continued their participation in the AAI interview after 1 year of treat-
ment were in the TFP group, suggesting greater compliance of these patients, which
may itself indicate a greater capacity to reflect on and tolerate a reevaluation of attach-
ment experiences, including those that involve traumatic abuse or loss.
Speaking to this point, a recent analysis by Tmej and colleagues (Tmej A, Fischer-
Kern M, Doering S, et al. Changes in attachment representation in psychotherapy: is
reflective functioning the crucial factor? Unpublished manuscript) from the same data-
set showed that higher RF level before psychotherapy proved to be a moderator for
change in attachment representation. Patients with unresolved attachment and low-
level RF at the outset had the least chance for representational change during the first
year of psychotherapy.
SUMMARY
As Draijer and Van Zon72 point out, “in extremely traumatized patients there may be
aggressive and oppressive inner parts that want control” (p. 170), and these may vie
with vulnerable and fearful aspects of the self. Further these opposing representations
are seen to be a mélange of objective and subjective experiences colored by the BPD
patient’s own extreme and polarized affect states. These opposing and contradictory
aspects of self may contend with each other. The self as victim fearing attack from an
abusive other oscillating with an enraged self-attacking a helpless other, with the latter
often split off and dissociated. All of these highly polarized, contradictory aspects of
self and others are mobilized, explored, and then interpreted as they emerge through
the experience in the transference, leading to their modulation and integration. Our
findings are thus consistent with the putative mechanisms of change in TFP, that might
result from the integration of polarized affect states and self-other representations into
a more coherent whole.58 Such intrapsychic changes might be relevant for long-term
treatment benefits.57,73 In sum, so far TFP is the only evidence-based treatment
demonstrating changes in attachment representations (from insecure to secure and
disorganized to organized), and in RF after 1 year of treatment in individuals with BPD.
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