Wednesday, February 6, 2013

Attachment Studies with Borderline Patients: A Review - Part 2


Ready for part 2? Honestly if you’ve been following along the results shouldn’t surprise you at all. I think it’s really important to know that there has been extensive research put into this subject. It’s validating for me to see that it’s not just me that has these feelings and that it’s not just “coming out of nowhere”. You can find Part 1 HERE and the article in it's original form: HERE. So let’s get to the results!  

Attachment Studies with Borderline Patients: A Review - Continued


RESULTS


Attachment Types That Characterize BPD


Secure Attachments

>>>> Since all the theories discussed earlier, as well as the standard DSM description, indicate that, by definition, borderline subjects' relationships are not secure, it is of some interest that a fraction of borderline patients in these studies were found to be categorized as secure. Although two of the five studies utilizing the AAI showed that none of the individuals with BPD had secure attachment,36,37 the other three of those studies13,38,44 showed small percentages—either 7% or 8%—that did. Moreover, two studies using self-report measures39,40 found that 9% and 29.8% of the BPD subjects had secure attachment. The other four studies did not report the proportion of secure attachment among the BPD patients. All studies demonstrated an inverse relationship between secure attachment and BPD when the disorder was rated in a dimensional fashion. Fossati and colleagues41 reported a lower mean confident (that is, secure) score among BPD subjects than nonpatients (p = .0025). Dutton,35 Nickell,43 and their colleagues showed that their dimensional ratings of borderline pathology were highly negatively correlated to secure attachment (p = .001 and p = 0.01, respectively). Meyer and colleagues42 demonstrated a negative correlation between secure attachment and each of the 13 personality disorders that they examined; the negative correlation was most robust for the borderline scale (p = .01).

>>>> While all the theories that have been discusses, as well as the standard DSM description, indicate the, by definition, Borderline subjects are not secure in their relationships, it was found that a fraction of Borderline patients in these studies were found to have secure relationships. It may have only been 7%-8% in those studies but it’s still interesting to note that some Borderlines come by this naturally. It was also seen that the more severe the symptoms of BPD the less secure the Borderlines relationships seem to be. As to be suspected it was also seen that people with BPD have lower confidence (secure attachment) than people without BPD. Meyer and colleagues found lower secure attachment in all of the personality disorders they studied, but this was most evident with Borderline Personality Disorder.

Insecure Attachment


>>>> All of the studies revealed an association between the diagnosis of BPD and insecure forms of attachment. Of the seven studies employing the categories preoccupied or unresolved, the five using the AAI all showed that the greatest proportion of borderline individuals fall into these attachment types.13,34,35,38,44 In the two studies using self-report measures of preoccupied attachments35,40—which, as shown in Table 1, is a somewhat different construct—the results were different. For Patrick and colleagues,36 all 9 of the borderline patients who had experienced loss or trauma were given a primary classification as unresolved with respect to loss or abuse, as well as a secondary classification as preoccupied. Three additional patients with BPD were given a primary classification of preoccupied. Ten out of the 12 patients with any preoccupied classification were assigned to a rare preoccupied subtype termed “confused, fearful, and overwhelmed” by traumatic experiences. Stalker and colleagues37 found 7 out of the 8 women with BPD were given a primary classification of unresolved, and 5 of 8 were given a primary or secondary classification of preoccupied. Fonagy and colleagues13 described 32 of 36 patients with BPD (89%) as having a primary classification of unresolved, and 27 of 36 patients (75%) as having a primary or secondary classification of preoccupied. Barone44 found that out of 40 BPD patients, 50% were given a primary classification of unresolved; 23%, of preoccupied; and 20%, of dismissing. Rosenstein and Horowitz38 found 8 of 14 adolescents with BPD (64%) to have a preoccupied attachment style. This study did not assess unresolved attachment. The two studies that used self-report measures found that fearful attachment characterized BPD. For Dutton and colleagues,35 both fearful and preoccupied attachment, as assessed by the RQ and RSQ in abusive men, were predictive for borderline personality, but fearful attachment was so strong a predictor that the authors concluded that having borderline personality was the prototype for this particular attachment style. Using the RQ and their overinclusive sample of students, Brennan and Shaver40 found that 32.2% were fearful; 24.6%, preoccupied; 13.4%, dismissing; and 29.8%, secure.

>>>> All of the studies revealed an association between the diagnosis of BPD and insecure forms of attachment. Of the 12 studies covered all showed Borderline individuals falling into the categories of Preoccupied or Unresolved. For Patrick and colleagues, all 9 of the borderline patients who had experienced loss or trauma were given a primary classification as unresolved with respect to loss or abuse, as well as a secondary classification as preoccupied. Three additional patients with BPD were given a primary classification of preoccupied. Ten out of the 12 patients with any preoccupied classification were assigned to a rare preoccupied subtype termed “confused, fearful, and overwhelmed” by traumatic experiences. Stalker and colleagues37 found 7 out of the 8 women with BPD were given a primary classification of unresolved, and 5 of 8 were given a primary or secondary classification of preoccupied…… all results showed a high correlation between Insecure Attachment and BPD. In fact for one fearful attachment was so strong a predictor that the authors concluded that having borderline personality was the prototype for this particular attachment style.

Fossati and colleagues41 found that inpatients and outpatients with BPD scored significantly higher than non-patients on all insecure dimensions. This result suggests that the combination of unresolved and preoccupied or fearful classifications may serve to identify a complex combination of insecure features. Consistent with the complexity of insecure features, West and colleagues34 found that high scores on each of four attachment scales—feared loss, secure base (coded negatively), compulsive caregiving, and angry withdrawal—successfully distinguished patients with BPD among 85 female outpatients. They found that a dependent style of attachment was associated with less BPD pathology than an avoidant or an ambivalent style. Finally, Meyer and colleagues42 found that three patients with BPD scored very highly on the study's measure of borderline attachment prototype, which is defined as “ambivalent and erratic feelings in close relationships.” 

Across the board it is seen that Borderline patients score significantly higher than non-patients on all Insecure dimensions. This result suggests that the combination of ‘unresolved’ and ‘preoccupied’ or ‘fearful’ classifications may be very helpful to identify the complex combination of insecure features seen in BPD. It was also found that female Borderline patients scored very high in each of four attachment styles distinguished by – feared loss, insecure base, compulsive caregiving, and angry withdrawal. They also saw that the BPD pathology is more highly associated with an avoidant or ambivalent style than with a dependent style of attachment. It was also found that some BPD patients scored very highly on the study’s designation of the “borderline attachment prototype”, which is defined as: ambivalent and erratic feelings in close relationships.”

            
 DISCUSSION

These studies of borderline personality employ a variety of measures and types of insecure attachment. Moreover, the target relationship varies in the different studies from one with peers, parents, or a generic other. These variations make comparisons between studies difficult (see reviews by Stein and colleagues14 and by Crowell & Treboux).27 The attachment field sorely needs studies that document the correlations among the different attachment types identified by the various instruments. The particular area reviewed here also still needs large samples of carefully diagnosed borderline patients with matched comparison groups. For the present review, we must rely on our hypothesized correlations among the attachment types—hypotheses based on the concordance of, or differences between, the definitions posited by each instrument. Moreover, the studies under review have utilized varied sources for sample acquisition (colleges versus hospitals, for example), various comparison groups and diagnostic methods, and generally small sample sizes. Finally, these studies have used measures developed to describe attachment styles among nonclinical populations. Arguably, however, rather than attempting to fit attachment patterns seen in high-risk or clinical samples into descriptors developed for normative populations, what is needed is further description of the specific attachment behaviors and internal models characteristic of the clinical groups themselves; these patterns are likely to be more complex and contradictory than those prevalent in nonclinical samples (for example, see additional AAI codes for hostile-helpless states of mind developed by Lyons-Ruth and colleagues).50 The conclusions to be drawn from this review are thereby greatly limited and should be considered, at best, as informed hypotheses.

Despite the great variation in study design and methodology, all 13 of the studies relating attachment to BPD concluded that there was a strong association with insecure forms of attachment. This finding is consonant with theories that see interpersonal instability as the core of BPD psychopathology. Still, given that BPD samples were defined, in part, by DSM criteria that include intense and unstable relationships as a diagnostic feature, this result is somewhat circular. A recent report by Meyer and colleagues42 illustrates this point. They found that their Borderline Attachment Prototype correlated so highly with borderline criteria that only a single variable could be used in a regression analysis. Nonetheless, this result suggests that despite measures that differ substantially, all are capturing some essential subsyndromal—that is, phenotypic—problems in the interpersonal relationships of borderline individuals. The one exception to this pattern of insecure attachments—the study by Brennan and Shaver,40 with nearly 30% of the subjects having secure attachment—is likely a consequence of the study's highly over inclusive method of sampling. Indeed, given the emphasis on interpersonal problems in borderline psychopathology, it would seem that anytime secure attachment is found, either the diagnosis or the attachment measure should be considered suspect.

The most consistent findings from this review are that borderline patients have unresolved and fearful types of attachment. In all studies using the AAI, from 50% to 80% of borderline patients were classified as unresolved. In the two studies using self-report instruments that assessed fearful attachment, that classification was the one most frequently associated with borderline features (among abusing men and college students).

It is notable that all unresolved subjects were also secondarily classified as preoccupied. Moreover, in the self-report studies that included a fearful classification, preoccupied attachment was the second most strongly endorsed category among borderline subjects. In no study that included the unresolved or fearful classification, however, was preoccupied the most prevalent classification. Preoccupied (or ambivalent) attachments are defined as ones in which individuals seek close, intimate relationships but are very reactive to their perceived dependency or undervaluation. This description is close to what Meyer and colleagues42 defined as the prototypic borderline form of attachment—that is, “ambivalent and erratic feelings in close relationships.” The characterization as fearful also entails a longing for intimacy, but fearful individuals are concerned about rejection rather than excessive dependence. Patrick and colleagues36 bridged these types by demonstrating that borderline patients had a fearful subtype of preoccupied attachment (as well as being unresolved). In sum, then, BPD attachments seem best characterized as unresolved with preoccupied features in relation to their parents, and fearful or, secondarily, preoccupied in their romantic relationships. While in our view and that of others,51 the self-report fearful category and the AAI unresolved category seem to overlap, such an overlap remains to be demonstrated empirically.

The high prevalence and severity of unresolved/preoccupied (AAI) or fearful (self-report) attachments found in these adult samples support the central role that interpersonal relationships have had in clinical theories on BPD. Insecure attachments, especially of unresolved or fearful type—or their disorganized analogues in infancy and childhood—might serve as markers of risk for development of BPD. This hypothesis invites other research in which these forms of insecure attachment in adults could be used as a subsyndromal phenotype* signifying a predisposition to BPD that takes its place alongside the phenotypes of affective instability and impulsivity as predisposing toward BPD.6 Such possibilities are confirmed by evidence that disturbed attachments may have inheritable components.52-54 Family-study methodology could usefully test whether a BPD-related risk factor exists in the form of unresolved or fearful attachments that are transmitted across generational boundaries.

*Subsyndromal phenotype essentially means: The observable characteristics, such as behaviour, that result from the interaction of someone’s total genetic makeup with the environment, but which aren’t severe enough to be considered a full blown syndrome for clinical diagnosis.


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So there you have it! It has been found in nearly every case studied that attachment issues are a significant factor in Borderline Personality Disorder. It’s so prevalent in fact that these researchers believe it should be looked at specifically in diagnosis. Not only are these issues a result of early childhood development, but they are also inheritable to some extent. Insecure attachment types should really come as no surprise to any of us that actually have to live with BPD. So I guess all you really need to know from this article is that this subject has be extensively studied in regards to BPD and the unanimous conclusion is: Yes, people with BPD overwhelmingly are shown to have insecure attachment styles, especially unresolved and preoccupied types, and furthermore with fearful types. Research was also able to see that the roots of erratic and ambivalent attachment issues, which are typically spelled out in the DSM are likely a result of these issues as well. This is even more apparent with patients that had a history of abuse and trauma. Shocking, I know! But it is nice to have the clinical validation of this experience. 

1 comment:

  1. This explains a lot and what I'd find extremely useful are some examples I.e. how does this manifest in a close relationship - what does it actually look like?

    ReplyDelete

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