The Implications Of Attachment Theory And Research For Understanding Borderline Personality Disorder
Lorrine Hatala
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Borderline personality disorder (BPD) is a highly prevalent, chronic, and debilitating psychiatric problem characterized by a pattern of chaotic and self-defeating interpersonal relationships, emotional lability, poor impulse control, angry outbursts, frequent suicidality, and self-mutilation. Recently, psychopathology researchers and theorists have begun to understand fundamental aspects of BPD such as unstable, intense interpersonal relationships, feelings of emptiness, bursts of 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. These investigators have noted that the impulsivity, affective lability, and self-damaging actions that are the hallmark of borderline personality occur in an interpersonal context and are often precipitated by real or imagined events in relationships. This article reviews attachment theory and research as a means of providing a developmental psychopathology perspective on BPD. Following a brief review of Bowlby's theory of attachment, and an overview of the evidence with respect to the major claims of attachment theory, I discuss individual differences, the evidence that these differences are rooted in patterns of interaction with caregivers, and how these patterns have important implications for evolving adaptations and development. Following this discussion, I present recent work linking attachment theory and BPD, focusing on the implications for understanding the etiology and treatment of BPD. In conclusion, I address some of the salient issues that point to the direction for future research efforts.
Researchers are not sure exactly why and how BPD develops, but they think it usually results from a complex interaction of biological, environmental, and psychosocial factors. The developmental journey looks different in every individual and may take a wide range of different paths.
In recent years, researchers have started to explore the links between BPD and attachment styles. Shaped by the way young child attaches to their parents, secure, insecure, and fearful attachment styles describe the way we form and maintain relationships with others. Some researchers have proposed that:
This blog offers some information about attachment theory and how it may explain some of the symptoms of BPD. It also provides an outline of treatment for the condition and how it can help young people to manage symptoms and build fulfilling futures.
Attachment styles are formed by the early interactions between a parent and their child. These first relationships have a huge impact on the emotional and social development of an infant, affecting the neurobiology of their brains and shaping the way they attach to others throughout the rest of childhood, adolescence, and into their adult lives.
In many cases, these attachment styles continue into adolescence and adulthood. Young people with avoidant attachment styles may be reluctant to form close relationships and avoid intimacy with others. Those with anxious styles may become controlling over another person, seeking to ensure that they do not leave. Teenagers and adolescents with disorganised attachment may rapidly switch between anxious and avoidant traits, sometimes clinging to another and at other times detaching.
They suggest that people living with the disorder often have a hyperactive attachment system that may have developed as a result of insecure attachments or the experience of traumatic events. Individuals with hyperactive attachment systems may quickly and intensely attach to another as though they are dependent on them for their survival. This may lead to some of the interpersonal difficulties associated with BPD, such as:
Young people with borderline personality disorder often have difficulty mentalising. They may think that if a person leaves for a short amount of time, they have left them forever and not consider that they have an intention to return. They may also be quick to act according to a certain feeling without considering that the feeling may be rooted in other factors and not present the best course of action.
Instead, they may feel overwhelmed by their affection, desires, and fears, and act following these emotions. They also suggest that, in some cases, this lack of mentalisation could be rooted in experiences of mistreatment as a child, who may be reluctant to consider the destructive thoughts and feelings a caregiver has towards them.
BPD can look very different from one young person to another. This means that it can be hard to generalise both the symptoms and underlying causes of the disorder. However, despite these difficulties, researchers have noticed certain core features that many people living with BPD experience.
One of these observations is that many people living with BPD show patterns of anxious and disorganised attachment. They may have a painful intolerance of aloneness, an expectation of hostility from those around them, fewer positive memories of social interactions, and a hypersensitivity to their social environment. These traits, which cluster around insecure attachments, often seem to constitute some of the most significant characteristics of individuals living with the disorder.
Other studies have explored the role attachment styles may play in the development of BPD. One study found that children with insecure attachment and separation anxiety were more likely to show traits of the disorder. Another study found that teenagers who were overly close with their friends or untrusting of the world around them were more likely to show features of BPD.
Understanding the significance of insecure attachment among young people with BPD may help therapists and other mental health professionals treat the disorder. By working with young people to understand the roots of their attachment styles and developing the skills to form more secure attachments with others, young people may be able to manage and overcome many of the interpersonal difficulties associated with the condition.
There are several different kinds of therapy that can effectively treat BPD, helping young people understand and accept their emotions while learning skills that promote positive change. Treatment for BPD often involves group therapy sessions, providing the space for young people to develop meaningful and secure relationships with both their therapists and other people living with BPD.
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Many young people in Hong Kong have symptoms of anxiety, depression, and other mental health disorders, both in primary school and secondary school. Mental health disorders not only harm the well-being of children and adolescents but also their mental health in the future.
Many clinicians are still reluctant to diagnose BPD in adolescents before they are 18. Stigma and misconceptions surrounding personality disorders cause clinicians to avoid the diagnosis, despite strong evidence that many young people show stable and persistent BPD symptoms. Instead, young people may be diagnosed with anxiety disorders, mood disorders, or psychotic disorders.
Bullying involves deliberate harmful actions from one person or group of people to another, where there is a power imbalance between those bullying and those being bullied. This power imbalance may be physical or social, based on characteristics like popularity, social group, or age.
Persistent problems in emotional regulation and interpersonal relationships in borderline patients can be understood as developing from difficulties in early dyadic regulation with primary caregivers. Early attachment patterns are a relevant causal factor in the development of Borderline Personality Disorder (BPD).
Links between attachment issues, early history of neglect, and traumatic experiences, and symptoms observed in patients with BPD as per the DSM-5 classification (American Psychiatric Association: Diagnostic and statistical manual of mental disorders: DSM-5 (Fifth ed.). Washington, D.C; (2013)) are described in this article, while delineating possible pathways from attachment disruptions to the specific symptomatology of these patients. The theory of structural dissociation of the personality (TSDP) provides an essential framework for understanding the processes that may lead from insecure early attachment to the development and maintenance of BPD symptoms.
Borderline personality disorder (BPD) is characterized by many difficulties, including severe and persistent problems in emotional regulation and interpersonal relationships [1]. Borderline features are related to increased vulnerability to co-occurring moods, anxiety and eating disorders, and substance or alcohol abuse. In patients with BPD, core problems associated with impulse control and self-regulation tend to create other difficulties, such as angry outbursts, impulsive and self-mutilating behavior, fear of loneliness, identity disturbance, and a profound sense of emptiness. All these factors are interrelated and feed off each other [2].
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