A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder

The precise nature and etiopathogenesis of borderline personality disorder (BPD) Continues to elude researchers and clinicians. Yet, increasing evidence from various strands of research converges to suggest that affect dysregulation, impulsivity, and unstable relationships constitute the core feature,,, of BPD. Over the last two decades, the mentalization-based approach to BPD has attempted to provide a theoretically consistent way of conceptualizing the interrelationship between these core features of BPD. with the aim of providing clinicians with a conceptually sound and empirically supported approach to BPD and its treatment. This paper presents an extended version of this approach to BPD based oil recently accumulated data. In Particular, We Suggest that the core features of BPD reflect impairments in different facets of mentalization, each related to impairments in relatively distinct neural circuits underlying these facets. Hence, we provide a comprehensive account of BPD by showing how its core features are related to each other in theoretically meaningful ways. More specifically, we argue that BPD is primarily associated with a low threshold for the activation of the attachment system and deactivation of controlled mentalization. linked to impairments in the ability to differentiate mental states of self and other, which lead to hypersensitivity and increased susceptibility to contagion by other people's mental states, and poor integration of cognitive and affective aspects of mentalization. The combination of these impairments may explain BPD patients' propensity for vicious interpersonal cycles, and their high levels of affect dysregulation and impulsivity. Finally, the implications of this expanded mentalization-based approach to BPD for mentalization-based treatment and treatment of BPD more generally are discussed

Attachment, mentalization, and the self

Mentalizing is often simplistically understood as synonymous with the capacity of empathy toward other people. In fact, mentalizing comprises a spectrum of capacities that critically involve the ability to see one’s own behavior as coherently organized by mental states, and to differentiate oneself psychologically from others. It is these capacities that tend to be noticeably absent in individuals with a personality disorder (PD), particularly at moments of interpersonal stress. In this chapter, we will attempt to demonstrate that such impairments in mentalizing are at the heart of our explanatory framework for conceptualizing PDs. The foundations of our thinking lie in attachment theory, but, according to our most recent formulation, the heart of the relationship between mentalizing and personality pathology lies in the capacity of engaging productively in communication, and more specifically, in the quality of epistemic trust the individual possesses in relationships and, formatively, in the relationship between the child and his/her primary caregivers. Epistemic trust is defined in terms of an individual’s experience of communication from others, specifically, the ability to receive and treat new knowledge from others as personally relevant and therefore capable of modifying durable representational structures pertaining to self, others, and interpersonal relationships. Underpinning this capability is the consideration of the informant as a “trustworthy” source likely to communicate information that is generalizable and relevant to the self

A clinically relevant model of osteoinduction: a process requiring calcium phosphate and BMP/Wnt signalling

In this study, we investigated a clinically relevant model of in vivo ectopic bone formation utilizing human periosteum derived cells (HPDCs) seeded in a Collagraft carrier and explored the mechanisms by which this process is driven. Bone formation occurred after eight weeks when a minimum of one million HPDCs was loaded on Collagraft carriers and implanted subcutaneously in NMRI nu/nu mice. De novo bone matrix, mainly secreted by the HPDCs, was found juxta-proximal of the calcium phosphate (CaP) granules suggesting that CaP may have triggered the 'osteoinductive program'. Indeed, removal of the CaP granules by ethylenediaminetetraacetic acid decalcification prior to cell seeding and implantation resulted in loss of bone formation. In addition, inhibition of endogenous bone morphogenetic protein and Wnt signalling by overexpression of the secreted antagonists Noggin and Frzb, respectively, also abrogated osteoinduction. Proliferation of the engrafted HPDCs was strongly reduced in the decalcified scaffolds or when seeded with adenovirus-Noggin/Frzb transduced HPDCs indicating that cell division of the engrafted HPDCs is required for the direct bone formation cascade. These data suggest that this model of bone formation is similar to that observed during physiological intramembranous bone development and may be of importance when investigating tissue engineering strategies.Published versio

Psychodynamic psychotherapy for patients with functional somatic disorders and the road to recovery

Patients with functional somatic disorders (FSDs) are commonly encountered in clinical practice and are often considered difficult to treat. This article summarizes recent advances in the understanding of these disorders that have opened new avenues for treatment. Findings concerning the role of three related key biobehavioral systems (attachment, mentalizing, and impairments in epistemic trust) that seem to be centrally involved in FSDs, as viewed from a psychodynamic perspective, are discussed as well as empirical evidence supporting the efficacy of psychodynamic psychotherapy for patients with FSDs. Finally, the basic treatment principles of dynamic interpersonal therapy, an integrative psychodynamic treatment adapted for patients with FSDs, are outlined through a description of the treatment of a woman with chronic widespread pain and irritable bowel syndrome

The stress–reward–mentalizing model of depression: An integrative developmental cascade approach to child and adolescent depressive disorder based on the research domain criteria (RDoC) approach

The Research Domain Criteria (RDoC) propose a much-needed change in approach to the study of vulnerability factors implicated in mental disorders, shifting away from a categorical, disease-oriented model to a dimensional approach that focuses on underlying systems implicated in psychopathology. In this paper we illustrate this approach with a focus on the emergence of depression in childhood and adolescence. Based on evolutionary biological and developmental psychopathology considerations, we present an integrative developmental cascade model of depression that essentially suggests that depression emerges out of a three-pronged series of interacting impairments in the domains of stress regulation, reward, and mentalizing. We discuss the relation of these impairments to the five domains proposed by RDoC. We also focus on how this model may explain in large part the marked comorbidity of depression with other psychiatric disorders, as well as with functional somatic and somatic disorders. Limitations of this theoretical approach are discussed, as well as implications for the development, evaluation, and dissemination of interventions aimed at preventing or treating depression

Integrating and differentiating personality and psychopathology: a psychodynamic perspective

Several strands of research converge to suggest that personality and psychopathology can be integrated in the form of a hierarchical model of individual differences. The notion that personality and psychopathology are intrinsically linked has a long tradition within psychodynamic approaches. In this article, we first summarize empirical evidence supporting two related key assumptions of psychodynamic approaches to personality and psychology: that a developmental, person-centered approach is needed to complement a static, disorder-centered approach in the conceptualization and treatment of psychopathology; and that personality and psychopathology are best conceptualized as dynamic attempts at adaptation. Research in each of these areas supports the notion that personality and psychopathology are difficult to separate and may be moderated by severity (i.e., general psychopathology) such that increasing levels of severity result in increased intrinsic coupling between the two. We then discuss these findings in the context of a newly emerging social-communicative approach to human development that suggests that personality and psychopathology are better conceptualized in terms of a disorder of social communication, and that the purported rigidity and stability typically attributed to them are largely explained by the stability of the environmental mechanisms that underpin them, rather than by stable intrapersonal traits. The implications of these new views for the future of the science of personality and psychopathology, and for treatment strategies, are discussed

A Hierarchical Multiple-Level Approach to the Assessment of Interpersonal Relatedness and Self-Definition: Implications for Research, Clinical Practice, and DSM Planning

Extant research suggests there is considerable overlap between so-called 2-polarities models of personality development; that is, models that propose that personality development evolves through a dialectic synergistic interaction between 2 key developmental tasks across the life span—the development of selfdefinition on the one hand and of relatedness on the other. These models have attracted considerable research attention and play a central role in DSM planning. This article provides a researcher- and clinicianfriendly guide to the assessment of these personality theories. We argue that current theoretical models focus on issues of relatedness and self-definition at different hierarchically organized levels of analysis; that is (a) at the level of broad personality features, (b) at the motivational level (i.e., the motivational processes underlying the development of these dimensions), and (c) at the level of underlying internal working models or cognitive affective schemas, and the specific interpersonal features and problems in which they are expressed. Implications for further research and DSM planning are outlined

Rejection Sensitivity and Borderline Personality Disorder Features: The Mediating Role of Attachment Anxiety, Need to Belong, and Self-Criticism

Rejection hypersensitivity has been considered to be the core feature of borderline personality disorder (BPD) patients. However, little is known about the possible developmental mechanisms that might explain the association between rejection sensitivity and BPD features. The current study investigated the mediating roles of adult attachment, need to belong, and self-criticism in the association between rejection sensitivity and BPD features in 256 healthy adults. Results indicated attachment anxiety, need to belong, and self-criticism mediated the association between rejection sensitivity and BPD features. However, attachment anxiety and self-criticism did not moderate the mediated association between rejection sensitivity and BPD features. The findings suggested that individuals with high rejection sensitivity were more likely to be anxiously attached to significant others, which might increase the desire to be accepted by others. To satisfy this elevated need to affiliate with others, they might become more self-critical which may contribute to high BPD features

Rethinking the relationship between attachment and personality disorder

Attachment approaches have played a crucial role in furthering our understanding of individuals with personality disorders (PDs) and their treatment. Yet, recent years have witnessed the emergence of a number of findings that urge us to reconsider the role of attachment in PDs. Besides the overlap between conceptualizations of attachment and core features of PD, there is increasing evidence that the link between childrearing environments, including attachment contexts, and later outcomes is less substantial than often assumed. Here, we summarize these findings and propose a novel approach to the role of attachment in PDs by situating attachment within a broader socio-communicative approach to PDs. This approach involves a reconceptualizing of attachment as an adaptation strategy to a given environment, with attachment contexts being only one, albeit important, context to learn about the social environment. Evidence for these assumptions is reviewed, and clinical implications discussed