Friday, February 8, 2013

Ask Haven: Can we still be Friends?

Today is supposed to be a Lucid Analysis day but I just don’t want to listen to myself rant. So we’re going to do an Ask Haven instead!

A Reader asks:

            Dear Haven,

My BPD gf and I broke up recently but I still want to be friends. She won’t even talk to me though! She said we could be friends but she won’t return any of my texts or calls.  It’s been 2 months! How can I get her to stop ignoring me?

Dear Ignored,

            First, congratulations on having a breakup that didn’t end in mutual hatred and loathing. That’s the dream.

            Second. You need to back off a little bit. You may be ready to be friends right away, but it doesn’t take a whole lot of reading in between the lines to see that she’s not. If you keep pushing you’re going to push away any hopes of a friendship completely.

There are a lot of reasons why we need space and maybe not the ones you’re thinking of.

1.      We need time to really get over you. Even if you say it’s over, even if we want it to be over, doesn’t mean feelings are spontaneously resolved. Unless there were no feelings there at all (and I’ve certainly had those relationships) then there are still things that need to be overcome. If we don’t have the space to move on, those feelings don’t just dissipate. They sit there, somewhere between our stomach and our throat threatening to compress our heart into a shriveled ball of resentment.  

2.      Hope remains. Especially if we’re not the one that ends it there may still be some small spark of hope. That’s only further stoked by the constant affirmation that we’re a good enough person to still keep in your life as a friend. Every kindness, every kind word, every decently human gesture is a question mark asking whether or not that means feelings are still there for something to be rebuilt upon. Being a constant presence just keeps those embers stoked. That’s not in a good way if the goal is to move on.

3.      Even if you know in your heart of hearts and at the very front of your brain that you don’t want to be with that person, because you broke up for all of the right very valid reasons, if they’re constantly in your personal sphere – feelings can inexplicably creep in and lead to the desire for impulsive bad decisions. And a relationship relapse that will only end in regret.

4.      Pain doesn’t end with good-bye. Regardless of who broke up with who, she may still be in a lot of pain. My last break up was very painful for me, even though it was my decision. It took me a month to build myself up to seeing him in person, and that was only because the situation wasn’t avoidable. Just because the relationship is resolved doesn’t mean the heartache is. That takes time to recover from…

5.      Just because you’re ready doesn’t mean she is. People, even people without the emotional sensitivity of BPD, need time to get over a break up before they feel functionally capable of seeing their ex. With BPD, that time frame should probably be extended x3. The longer and more intense the feelings of the relationship, the longer the recovery time. You need to recognize that her feelings are probably different than yours.

6.      She may have just been being nice. Saying you can be friends is a time honored tradition of break up lies for the sake of decency. It’s just what people say when they break up.

7.      I’ve said it before and it may be the object constancy talking, but absence makes the heart grow colder. When you’re trying to squelch the flames of relationships past, this is exactly what you need. Take time apart. Wait til she’s rebound. Allow her to move on. You can’t truly be friends if those feelings haven’t chilled out.

You don’t get to choose for her when she’s ready. You don’t “get to make her stop” ignoring you. The best thing you can do is let her know you’re there as a friend when and if she’s ready, and step away. Give her the space she needs. 

Thursday, February 7, 2013

If you see it, please take a stand: Bullying

Now I’m just sad. Grumpy, then angry, then furious, and now sad.

I’ve posted this before but I think it’s worth revisiting. Bullying is nasty business. One of the few things I miss about living where I grew up is the people. People in general are so much nicer there. NYC is filled with so many bitter, cruel people. A friend of mine was being bullied earlier today so I interjected on her behalf. I was promptly attacked as well, but that didn’t bother me so much. I was furious but outwardly and in my words I kept my cool. A logical argument and reasoned words are the only way to deal with that. Plus none of them know me at all so nothing they could have to say to me had any impact.

I don’t know if it’s your experience, or a quirk of my personality, but for as sensitive and feeling as I can be, it’s only really the people that I care for that can cause me much harm. I know this isn’t true for others. It was astonishing to me that (1.) People are so self-important that they think they could have any influence over my life or thoughts, and (2.) that they think this kind of bullying is justified and acceptable? The level of harassment they’re putting my friend through is so extreme she moved out of the state to get away from them. And they’re still finding ways to harass her. It hurts my heart. So I’m reposting this as a reminder, a hope, that we can stand up to bullying and harassment. Staying silent may not be the same as doing the bullying, but it also doesn’t help bring it to an end. 

If there’s one thing I’m not, it’s silent. 

New Girl - Excited Aggravation

Geezus I’m in a bad mood today. This week has been really good. I just want to get this all out of my system. I’ll get to my real post later. 

Last Friday was my birthday. Again. I am now officially one day older than I was the day before. Good job to me for making it through another day without self-destructing.

So I had mentioned that I was thinking I might be ready to start dating again but I didn’t really know where to meet women anymore (since I don’t really do the bar/club thing anymore). I guess that’s all it takes though. A girl I met a couple years ago through Riot, contacted me. We’re FB “friends” and we’ve always done the casual comment thing, but I didn’t really know her. Apparently she’s had a crush on me for ages though and didn’t know how to approach me. Short story shorter… she asked for my number last night (last Thursday) and we talked on the phone for like 2 hours just getting to know each other.

She does live about an hour and a half away so it would be semi-long distance (not that long) but that would ensure that it doesn’t go too fast, right? And if I’m being honest I can see how it would make for some complications, but I think I’ll just take this a day at a time for now.

Anyways, as I was talking to her it struck me how much easier it is for me to open to women, or maybe just her, idk. We talked about things in that first 2 hours that I hadn’t been comfortable opening up to Tech Boy about in almost a full year of dating. It feels so much more natural and less threatening.  It’s a relief. I didn’t feel like I had to intentionally hide parts of me. It was probably very helpful that she is very open about herself and wasn’t afraid to be vulnerable herself.

 I feel ridiculous sometimes. I was smiling and laughing like a big goof.   

We’ve been talking on the phone every night since (and this with me and my phone anxiety which is barely an issue with her!). It’s been wonderful and a little scary at the same time.  I can definitely tell she’s the kind that rushes into things very quickly (which makes me balk a little), but at the same time we don’t have the means to pursue things that fast so maybe there’s some balance in that. She’s amazingly easy to talk to. Without even knowing it she’s been exceptionally comforting to me in her acceptance and admissions. She’s so open, it inspires the same openness in me. She’s also told me that one of her best friends struggles with eating disorders, self-harm, and BPD (her friend sounds more extreme than me by far)… so nothing I could reveal about myself would scare her away. It’s such a relief knowing that she understands the things I’ve dealt with. Don’t get me wrong, I haven’t told her the full extent of my issues yet, but unlike with Tech Boy, I actually feel like I can when it feels appropriate. It’s so odd to feel that kind of ease. And the things we have in common! It’s astonishing.

Speaking of Tech Boy, he’s still missing me quite a lot. He texted me last night and told me that I’d been on his mind constantly for the past week. He keeps thinking about what he did wrong and doesn’t believe it’s anything we couldn’t get past. I think it would be cruel to tell him I’m talking to someone new but I also don’t want him to wait for me. I managed to convey that I appreciated him and am happy to have him in my life, but that I don’t want a relationship, and I don’t want him to put his life on hold waiting for me. I think that was as tactful a way as I could have put it. It makes me sad though. Especially since I do still miss him at times; mostly when I’m around him directly or he keeps me in conversations. But that doesn’t change anything, nor do I want it to.

This week has been going so nicely!  For my birthday friends took me out to a really great dinner. Then afterwards we all went back to my place, and more friends joined us for drinks and hanging out. I’ve been so consumed with work I didn’t really plan anything, so this was all very last minute. Yet it was one of the best birthdays I can remember. I spent the whole evening nearly in tears from laughing. It’s such a platitude to say that laughter is the best medicine, but those kinds of sayings come about for a reason… because this one is so very true. Even just a couple years ago I don’t think I would ever have dreamed that I would laugh so much so often. It seems like a miracle sometimes. I still struggle with a lot, some times more than others, but none of it seems so fatal or futile as it used to. I remember how consumed in the darkness and despair I was for so many, many years, unable to contemplate that something might change for the better, wanting to end it all and give up… I’m very grateful I managed to hold on and continue through. It’s so difficult to believe things will get better when you’ve never experienced what better can be, but when it does, ::smiles::, it feels like everything else was a fog of a dream. Like you’ve been given a second chance. For me at least it’s even better though because I feel like I’ve earned it (at least at times). I’m still not sure if I deserve it, if I deserve happiness, but I feel like I’ve been able to take control of my life and steer it in a much better direction. And that’s certainly something.

<<< I wrote that two days ago >>>

 I was on the phone with her for nearly two hours last night. I’m already beginning to feel suffocated and aggravated with her. She is really, really needy. She thinks she comes across as “too aggressive”, but I think she comes off as terribly insecure. She keeps throwing all of the most personal information at me in a rapid paced barrage of confession. She barely takes a breath or lets me get a word in edge wise. She cuts me off and doesn’t let me finish thoughts (which Therapist does as well and I can’t stand it). Then she brought up her Borderline friend and how exasperated she’s been with her. She said some pretty inappropriate things in regards to her struggles and I was really offended. On the one hand I wanted to stop her and flat and tell her I was recovering BPD, she was being offensive, and her friend clearly needs helps. On the other I’m not sure I want to let her know because I don’t trust how she’ll handle it. Regardless, I’m annoyed.

She was going on and on about astrology. She’s really into it. I know enough about it to know that our signs aren’t technically compatible, but I also have zero interest or respect in the belief in astrology. I seriously resent the idea that who I am is a predetermined product of some arbitrary grouping of stars. Not to mention I studied astrophysics heavily at University and have actually calculated the tidal/force influence of the constellations. I’ve actually done the physics. The doctor/nurse/whoever that births you has a greater energetic influence over you than even the sun or the moon which are millions of miles closer. Astrology is utter bullshit.

Then she kept telling me how I feel. She’d say something, call herself an asshole or whatever for “coming on to strong”, and then would make a statement like “you’re probably annoyed”, “I’m probably scaring you”, “you must think I’m a jerk”….

… Do Not. Tell Me. What I Feel. Ever. EVER! 

This is probably my biggest pet peeves. First of all, in every instance she was wrong…. UNTIL she made a judgement on how I was feeling… at which point, yes I did become annoyed. I had no feelings one way or the other towards a lot of the things she was saying because it was just conversational stuff that didn’t really have much significance attached to it. But she’s known me for all of 6 days. She has zero clue how I am, or how I react to things. Especially when I’m simply being open and receptive, just listening, to everything she’s pouring into my ears.

CHILL THE FUCK OUT WOMAN! Just relax. It feels like she’s trying to fast track us on the road to deep emotional connection, instead of letting it happen naturally. I want to get to know her, but I don’t need to know EVERY SINGLE THING RIGHT THE FUCK NOW! It’s been 6 days and I feel like I know more about her deepest most private emotions and experiences than I do about xRoommate who is one of my best friends. It’s insane. She says she just wants to be up front about who she is. Fair enough. However, what it feels like is that she’s trying to inundate me with everything that could push me away, right now; so that I can make some kind of decision about her before she lets her feelings develop too far. It’s a tactic I’ve used before… setting myself up to be rejected to justify in some way that we weren’t really right for each other and I don’t have to feel so bad about myself if it doesn’t work.

Except the problem is it’s not even what she’s telling me. None of it is anything I haven’t been through myself and don’t completely understand, it’s just too much too fast.

And she needs SO MUCH attention. I didn’t text her one morning and she complained that I didn’t text her “as usual”. As usual? We’d only been talking for 4 days. We haven’t had time to develop “as usual” anything yet.
I know my feelings of suffocation aren’t just a product of my BPD either. I think this would be a little much for most people. We haven’t even gone on a first date yet! Which we are set up to do on Saturday.  She’s coming to the city to meet up with me and apparently has a whole day of splendid planned out.

I was so excited about this. Until last night. And now I’m just aggravated. ::sigh:: I feel like I’ve been clubbed over the head with the most aggressive snuggle ever. Flayed with emotion.

Oh! Also, she tried to justify her appreciation of Twilight because I like Star Wars. Excuse me? I wanted to punch her brain. Where do I find these people? 

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


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.”


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.


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. 

Tuesday, February 5, 2013

Attachment Studies with Borderline Patients: A Review - Part 1

All this build up talking about Attachment but what exactly does it have to do with Borderline Personality Disorder?!? I appreciate your patience, but you should know be by now. I need to be thorough and give you the most complete information I can find, so when we get to things like my post for today…. We’re all on the same page and have a strong understanding of where the research is coming from. Today’s article is brought to you from the Harvard Review of Psychiatry with contributions from the Department of Psychiatry at Harvard Medical School; McLean Hospital, Belmont, MA (Drs. Agrawal and Gunderson); Department of Psychiatry, Cambridge Hospital, Cambridge, and MA (Drs. Holmes and Lyons-Ruth). Pay special attention to the things I underline and expound on. I do this because some passages are cumbersome and filled with science jargon that doesn’t always feel accessible and I just want the information to be easy to read for everyone. If you see this >>>> it means I’ve interpreted the paragraph for easier reading. I’m going to do this in two parts because it’s extremely long.  I’ll talk about the Scope and Studies today and the Results and Discussion tomorrow. You can find the whole article HERE

Attachment Studies with Borderline Patients: A Review

Hans R. Agrawal, MD, John Gunderson, MD, Bjarne M. Holmes, PhD, and Karlen Lyons-Ruth, PhD


Clinical theorists have suggested that disturbed attachments are central to borderline personality disorder (BPD) psychopathology. This article reviews 13 empirical studies that examine the types of attachment found in individuals with this disorder or with dimensional characteristics of BPD. Comparison among the 13 studies is handicapped by the variety of measures and attachment types that these studies have employed. Nevertheless, every study concludes that there is a strong association between BPD and insecure attachment. The types of attachment found to be most characteristic of BPD subjects are unresolved, preoccupied, and fearful. In each of these attachment types, individuals demonstrate a longing for intimacy and—at the same time—concern about dependency and rejection. The high prevalence and severity of insecure attachments found in these adult samples support the central role of disturbed interpersonal relationships in clinical theories of BPD. This review concludes that these types of insecure attachment may represent phenotypic markers of vulnerability to BPD, suggesting several directions for future research.

Ever since the inception of the borderline personality disorder (BPD) diagnosis, clinical theorists- have suggested that the disorder's core psychopathology arises within the domain of interpersonal relations. These theories were prompted by the centrality of interpersonal demands and fears within clinical contexts. While there has been growing evidence and interest in biogenetic bases for borderline pathology,, these perspectives do not diminish the potential role that disturbed relationships have as risk markers or as mediating factors in BPD's pathogenesis.

>>>> Even though there is a significant amount of evidence that points towards a genetic component for the development of BPD, environmental factors still represent a potential cause for disturbed relationship and developmental issues in BPD.

In recent years the methodology for reliably measuring attachment styles has provided a welcome opportunity to characterize empirically the interpersonal problems of BPD patients. Because the insecure attachments of borderline patients are so manifest, so central to the problems that they present for treatment, and so central to theories about the pathogenesis of BPD, the empirical examination of these attachments has considerable clinical and theoretical significance. The resulting literature—still growing rapidly—is the subject of this review.


In the background of the attention being given to attachment problems in borderline patients is the seminal developmental theory of John Bowlby.- He postulated that human beings, like all primates, are under pressures of natural selection to evolve behavioral patterns, such as proximity seeking, smiling, and clinging, that evoke caretaking behavior in adults, such as touching, holding, and soothing. These reciprocal behaviors promote the development of an enduring, affective tie between infant and caregiver, which constitutes attachment. Moreover, from these parental responses, the infant develops internal models of the self and others that function as templates for later relationships. These models, which tend to persist over the life span, guide expectations or beliefs regarding interactions in past, present, and future relationships. For Bowlby, the content of the internal working model of self is related to how acceptable or lovable one is in the eyes of primary attachment figures. The content of an individual's model of other is related to how responsive and available attachment figures are expected to be.

The goal of attachment is the creation of an external environment from which the child develops an internal model of the self that is safe and secure. Secure attachment to the caregiver liberates the child to explore his or her world with the confidence that the caregiver is available when needed. A secure attachment should engender a positive, coherent, and consistent self-image and a sense of being worthy of love, combined with a positive expectation that significant others will be generally accepting and responsive. This portrait of secure attachment contrasts dramatically with the malevolent or split representations of self and others, as well as with the needy, manipulative, and angry relationships, that characterize persons with BPD.,,

Fonagy and colleagues- have proposed that a child is more likely to develop a secure attachment if his or her caregivers have a well-developed capacity to think about the contents of their own minds and those of others. This secure attachment, in turn, promotes the child's own mental capacity to consider what is in the mind of his or her caregivers. In contrast, individuals with BPD demonstrate a diminished capacity to form representations of their caretakers' inner thoughts and feelings. In this way a child defensively protects himself or herself from having to recognize the hostility toward, or wish to harm, him or her that may be present in the parent's mind. In Fonagy's theory this diminished capacity to have mental representations of the feelings and thoughts of self and others accounts for many of the core symptoms of BPD, including an unstable sense of self, impulsivity, and chronic feelings of emptiness.

Several clinical theorists have posited intolerance of aloneness as a defining characteristic for BPD that provides coherence to the DSM's descriptive criteria., Gunderson subsequently suggested that this intolerance reflects early attachment failures, noting that individuals with BPD are unable to invoke a “soothing introject” in times of distress because of inconsistent and unstable attachments to early caregivers or, in Bowlby's terms, because of insecure attachment. Gunderson observed that descriptions of certain insecure patterns of attachment—specifically, pleas for attention and help, clinging, and checking for proximity that often alternate with a denial of, and fearfulness about, dependency needs—closely parallel the behavior of borderline patients.

 >>>> Comparing theories of object relations and attachment, Lyons-Ruth, has distinguished normal processes of separation-individuation in early development from the disorganized conflict behaviors displayed toward attachment figures by toddlers at risk for later psychopathology. She has argued that disorganized insecure attachment in infancy (see below) represents a deviant developmental pattern that, when present, may be an identifiable risk factor for the later development of BPD.

>>>> Lyons-Ruth compares the theories for object relations (like object constancy/permanency) and attachment. In healthy development there should be a secure sense of Self even during times of separation from attachment figures. However when the attachment to caregivers is more disorganized a behavioral conflict arises and indicates a potential psychopathology risk later in life. She argues that this disorganized insecure attachment style in infancy represents an abnormal developmental pattern that may be an identifiable risk fact for the later development of BPD.


Attachment in Infancy and Childhood

>>>> The empirical assessment of patterns of attachment behaviors began with Ainsworth and colleagues' typology of infant attachment behaviors toward their mothers when under stress. Under this typology, there were three organizations of infant attachment behavior: secure, avoidant, and ambivalent attachment (Table 1). In subsequent years, these infant behavioral patterns have been intensively researched, and a core body of empirical findings has been extensively replicated.

>>>> Ainsworth and colleagues originally discovered 3 classifications for infant attachment behavior: Secure, Avoidant, and Ambivalent.

Comparison of Attachment Types in the Traditions of Developmental Versus Social Psychology
Attachment in infancy/childhood—developmental tradition*Attachment between adults—social psychological tradition
Secure (autonomous)Secure

 Open communication of positive and negative affects with the caregiver Positive self-image and a sense of being worthy of love, combined with a positive expectation that others will be generally accepting and responsive


 Avoidant (dismissing) Dismissing/avoidant

  Restricted communication of vulnerable affects and deactivated attention to attachment needs  Positive self-image and a sense of lovability, combined with a negative expectation of significant others as demanding, clingy, and dependent

 Ambivalent (preoccupied) Anxious/preoccupied

  Exaggerated communication of vulnerable affects and hyperactivated attention to attachment concerns  Negative self-image and a sense of unlovability, combined with a positive evaluation of others (in terms of their strength and independence)

 Disorganized/disoriented (unresolved) Fearful/avoidant

  Contradictory, apprehensive, aimless, or conflicted behaviors in response to attachment needs  Negative self-image combined with a skepticism that significant others can be trusted to be loving and available

>>>> As infant attachment assessments were extended to high-risk or psychiatric samples, many of the infant behavioral patterns observed did not conform to any of the three attachment patterns characteristic of infants in low-risk settings. These repeated observations led Main and Solomon to review a large number of at-risk infant videotapes and develop coding criteria for a fourth category labeled disorganized/disoriented (Table 1). Disorganized attachment behaviors were subsequently found to be associated with family environments characterized by increased parental risk factors such as maternal depression, marital conflict, or child maltreatment. These attachment behaviors are also the behaviors most consistently associated with childhood psychopathology, including internalizing and externalizing symptoms at school age, as well as overall psychopathology and dissociative symptoms by late adolescence.

>>>> As studies continued to include high-risk individuals it was discovered that many of the infant behavioral patterns didn’t fit the previous 3 models. A new category was created to encompass these new patterns: Disorganized/disoriented. These disorganized attachment behaviors were subsequently found to be associated with family environments characterized by increased risk factors in the parents: such as maternal depression, marital conflict, or child maltreatment.

Attachment in Adulthood

A major step in the developmental research literature on attachment occurred with the introduction by Main and colleagues of the Adult Attachment Interview (AAI) in 1985. The AAI is a semi-structured interview developed to assess the adult counterparts of the secure, avoidant, and ambivalent attachment strategies observed during infancy and childhood. The interview lasts approximately one hour and poses a series of questions probing how the individual thinks about his or her childhood relationships with parents or other central attachment figures. The interview is coded not for the positive or negative content of childhood experiences or memories, but in terms of narrative analysis—that is, for how the individual organizes his or her attention and discourse regarding attachment topics over the course of the interview.

Adult strategies for discussing positive and negative attachment experiences in childhood are observable in the interview and parallel the infant strategies described earlier. Flexible and coherent discourse around both positive and negative attachment experiences is termed autonomous (the equivalent of secure in childhood); deactivating strategies are termed dismissing (the equivalent of avoidant); and hyperactivating strategies are termed preoccupied (the equivalent of ambivalent).

Shortly after the introduction of the AAI, Ainsworth and Eichberg reported that the parents' lapses in the monitoring of discourse or reasoning during discussions of loss or trauma on the AAI predicted disorganized attachment behaviors in their infants. This finding has now been well replicated, leading Main and Goldwyn to develop a fourth category for the AAI labeled unresolved with respect to loss or trauma. Unresolved attachment patterns are the only patterns that are also given a secondary subclassification (namely, unresolved/autonomous, unresolved/dismissing, or unresolved/preoccupied) that indicates which organized attachment classification is the best-fitting alternative classification. That is, since an unresolved classification is understood as indicating a collapse of strategy—as seen in the failure to use a single, consistent strategy over the course of the interview—the secondary classification is used to indicate the best guess as to the strategy that has failed.


Attachment Theory as Conceptualized Between Adults

Although Bowlby was primarily interested in young children, he maintained, as noted earlier, that the core functions of the attachment system continue throughout one's life span. In a series of independent developments in the field of social psychology, Hazan and Shaver were first to apply concepts of attachment developed from studies of the parent-child relationship to the romantic relationships found between adults. For example, feeling securely attached arises after receiving feedback from other adults that one is loved and capable. This inner sense of security contributes to a stable, consistent, and coherent self-image and to the ability to reflect upon and correctly interpret others. The social psychological tradition has defined secure, dismissing/avoidant, anxious/preoccupied, and fearful/avoidant attachment (Table 1)., To simplify, these types will hereafter be referred to as dismissing, preoccupied, and fearful.

Adult Attachment Self-Report Measures

>>>> In this study Hazan and Shaver expanded the attachment study to romantic relationships between adults. People were given an Attachment Self-Report (ASR) and asked to pick one of three paragraphs which best represented their relationships (Each paragraph demonstrated either a secure, anxious/ambivalent, or avoidant type). Bartholomew and colleagues worked to combine both socio-psychological and developmental attachment theories to understand attachment in adults. This was based on a combination of models that focus on the perception of the Self and that of others.
Security is defined as a Positive model of Self AND a Positive model of Others.  

>>>> Anxious/ambivalent (or preoccupied) is defined as Negative model of Self, combined with a Positive model of Others.

The Avoidant classification is split into two groups: Fearful and Dismissing.  
The Fearful group represents a Negative model of Self with a Negative model of Others.
The Dismissing group represents a Positive model of Self with a Negative model of Others.
To figure this out participants were given the Relationship Scales Questionnaire.

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If you’ve been following along with my other posts on Attachment you’ll recognize these group classifications. Stay tuned for tomorrows conclusion. 
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