Childhood Disruptions in Caregiving, Adult Parental Attachment, and Borderline Features in Emerging Adulthood: Rejection Sensitivity as a Mechanism of Influence.

Borderline personality disorder (BPD) is a severe psychiatric disorder first diagnosed in adolescence or emerging adulthood, which develops in part in the context of early attachment relationships. We tested a cross-sectional model linking caregiver disruptions during childhood, current parental attachment, and rejection sensitivity, to borderline features in 2,546 emerging adult college students. A structural equation model revealed that childhood caregiver disruptions were associated with lower quality adult parental attachment. Moreover, rejection sensitivity mediated the relationship between adult parental attachment and borderline features. Results suggest a representational model of others as rejecting links early disruptions in caregiving relationships and attachment insecurity, to borderline features in emerging adulthood. Implications for practice are discussed, including for means of targeting cognitive schemas related to rejection sensitivity, which could lead to reductions in BPD symptoms.

Sexual Abuse as a Risk Factor for Opioid Misuse in Pregnancy.

The purpose of this study was to identify a potential relationship between childhood sexual abuse and opioid misuse in pregnancy and to illustrate the need for better integration and collaboration between the medical and psychological disciplines to combat the opioid crisis. We sampled 93 pregnant women at a high-risk pregnancy clinic within a university medical center who were in their second trimester or beyond. Fifty-five women were considered high-risk due to opioid misuse and 38 women were considered high-risk due to medical reasons other than drug use. Our findings reveal both presence of and severity of sexual abuse were significantly associated with opioid misuse in pregnancy, while physical abuse, emotional abuse, and neglect were not. While childhood sexual abuse is a significant risk factor for opioid misuse in pregnancy, most doctors do not feel comfortable asking about trauma history. A public health approach to opioid misuse in pregnancy must consider how "diseases of despair" disproportionately impact women with limited access to adequate psychological and medical care. A preventative model of care, which targets screenings for ACEs in primary care and gynecological visits may help decrease the impact of sexual abuse.

Medication-assisted treatment vs. detoxification for women who misuse opioids in pregnancy: Associations with dropout, relapse, neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse.

The American College of Obstetricians and Gynecologists recommends medication-assisted treatment (MAT) for pregnant women who misuse opioids rather than detoxification because of possible relapse and dropout from treatment (ACOG, 2017). In a prospective study, fifty-five pregnant women with an opioid use disorder were offered a choice of MAT or detoxification. Ethical concerns precluded random assignment. We assessed dropout, treatment outcome, relapse, other illicit drug use, infant neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse. Of 55 women, 13 initially chose MAT and 42 women chose detoxification. All women received behavioral support. No one dropped out of treatment prior to delivery. All women who chose MAT initially remained on MAT. Of women who chose detoxification, 23% switched to MAT, 30% tapered below initial MAT doses, and 45% fully detoxified by delivery. There was a significant difference in opioid relapse between women on MAT (26%) and those who detoxified (0%), but no differences for other illicit drug use. Infants of women on MAT were more likely to have neonatal NOWS (91%) than infants of women who tapered below initial MAT doses but did not fully detoxify (62%). Infants of mothers who tapered (62%) were more likely to have NOWS than infants of women who fully detoxified (0%). Women on MAT reported significantly lower sexual abuse severity than did women who tapered or detoxified. It is critical to replicate the current findings and to follow up with mothers and their infants postpartum to ascertain the long-term impact of tapering or detoxification during pregnancy.

The borderline feature of negative relationships and the intergenerational transmission of child maltreatment between mothers and adolescents.

The current study examined the intergenerational transmission of child maltreatment in the context of maternal self-reported borderline features (affective instability, negative relationships, identity disturbance, and self-harm/impulsivity) and a maternal borderline personality disorder (BPD) diagnosis. We sampled 41 adolescents of 14 to 18 years of age and their mothers. A total of 19 mothers had a diagnosis of BPD, and 22 mothers were comparisons without the disorder. Results revealed that a maternal diagnosis of BPD was associated with physical abuse, physical neglect, emotional abuse, emotional neglect, and sexual abuse, but not supervisory neglect. Maternal BPD features were associated with emotional abuse, sexual abuse, and physical neglect, but not physical abuse, emotional neglect, or supervisory neglect. Results indicated that families whose mother had BPD experienced more intergenerational transmission of child maltreatment (regardless of perpetrator) between mothers and their adolescent offspring than did offspring of normative comparisons. Further, the borderline feature of negative relationships most strongly predicted transmission to the next generation. Neglect and overall maltreatment transmitted from mother to adolescent, whereas sexual abuse and physical abuse did not. Results are discussed in terms of the cascading impact of maltreatment across generations, particularly in families of mothers with BPD. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Pregnant women's history of childhood maltreatment and current opioid use: The mediating role of reflective functioning.

There is an association between the experience of childhood maltreatment and opioid misuse in adults, especially for women. However, we know little about this association in pregnancy, and less about processes that could be the target of interventions to help women better parent their infants. We examined reflective functioning as a putative process. Reflective functioning is the ability to interpret one's own and others' behavior in terms of underlying mental states, e.g., emotions, motivations, and beliefs. We sampled 55 pregnant women who misused opioids and 38 women at high risk due to medical factors, e.g., heart disease. We assessed maltreatment with the Maltreatment and Abuse Chronology of Exposure (MACE; Teicher & Parigger, 2015), and reflective functioning with the Reflective Functioning Questionnaire (RFQ; Fonagy et al., 2016). Maltreatment variables included the sum of severity across all subtypes, number of subtypes experienced, and severity of sexual, physical, and emotional abuse, and of neglect. We created a categorical opioid user group variable: women who used opioids in pregnancy vs. high-risk medical comparisons. We found that women who used opioids in pregnancy had poorer reflective functioning than did high-risk medical comparisons. We also created an opioid use severity scale (ranging from 0 to 3) from urine assays and history of prescribed opioids from medical records. Using Hayes (2012)'s bootstrapping PROCESS macro, we found that reflective functioning mediated the association between all maltreatment variables and opioid use severity. We discuss the results in terms of how best to intervene to improve women's reflective functioning, which may help their ability to parent.

Opioid use in pregnancy: Borderline features and Hepatitis C virus.

This study examined the relationship between borderline personality disorder assessed as self-reported borderline features (Morey, 1991), opioid use, and Hepatitis C virus (HCV) in pregnant women. There were 55 women in the opioid use group and 38 in the comparison group who were at high risk due to medical issues that did not include drug use. Women were in their 2nd or 3rd trimester. All women received Medicaid and were racially representative of the geographic area (84% White). We assessed opioid use severity from medical records based on urine assays and prescriptions for opioids. The results revealed that women who scored in the clinical range of total borderline features, which is associated with a diagnosis of borderline personality disorder (Trull, 1995), had 2.83 greater odds of being opioid users (prescribed and nonprescribed) than had individuals below the cutoff. The borderline features of affective instability, identity disturbance, negative relationships, and self-harm/impulsivity were significantly correlated with opioid use severity. Negative relationships and self-harm/impulsivity contributed significant variance in opioid use severity over and above affective instability and identity disturbance. Women in the clinical range of borderline features were more likely to have HCV than were women below the cutoff, and the borderline feature of negative relationships specifically was associated with HCV. We discuss implications for interventions to address negative relationships and self-harm/impulsivity and interventions to help prevent opioid misuse in women before they become pregnant. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Experience of Maltreatment in Young Children Whose Mothers Have Borderline Personality Disorder: Reflections in Their Narrative Representations.

Child maltreatment is an etiological factor in borderline personality disorder (BPD), which may be transmitted to the children of mothers with BPD. We assessed maltreatment in 36 children aged 4-7 whose mothers have BPD and in 34 normative comparisons. Children whose mothers have BPD were more likely to have experienced sexual abuse, physical abuse, and neglect than were normative comparisons. Mothers' self-reported borderline features were significantly correlated with children's maltreatment. Neglect was associated with mothers' affective instability, identity disturbance, negative relationships, and self-harm; sexual abuse was associated with mothers' identity disturbance, and negative relationships; and physical abuse was associated with mothers' self-harm. Maltreatment mediated the relationship between all four of mothers' borderline features and children's narrative representations of the caregiver-child relationship, which included fear of abandonment, role reversal, and mother-child relationship expectations. The authors discuss results in the context of risk for developing BPD in early adulthood and early preventive interventions targeting children's representations.

Mother-child role confusion, child adjustment problems, and the moderating roles of child temperament and sex.

Role confusion is a deviation in the parent-child relationship such that a parent looks to a child to meet the parent's emotional needs and abdicates, in part, the parental role in exchange for care, intimacy, or peer support from the child. In addition, a child may initiate role-confused behavior in order to gain closeness to a parent who is otherwise preoccupied by his or her own needs. The current study examined associations between mother-child role confusion at age 5 (we coded role confusion from filmed free-play mother-child interactions) and teacher reports of internalizing and externalizing symptoms, and peer problems, at Grade 1. The sample (N = 557) is from a longitudinal study of families in rural communities, the Family Life Project. Mother-child role confusion predicted internalizing symptoms and peer problems (but not externalizing symptoms) above and beyond other dimensions of maternal parenting (sensitivity and harsh intrusiveness), demographic factors, and prior levels of outcome variables. However, some effect sizes were small, making replication desirable. Temperament and child sex were important moderators: girls with difficult temperaments and boys with easy temperaments were more vulnerable to internalizing symptoms (but not externalizing symptoms or peer problems) in the context of role confusion. We discuss the singular importance of role confusion, a construct that has been largely unrecognized by developmental psychologists until recently, for behavioral outcomes of children as they transition into middle childhood. (PsycINFO Database Record

Empirical Studies Addressing the Opioid Epidemic: An Urgent Call for Research.

Opioid misuse has become one of the most pressing public health problems facing the country. In this article, we briefly review literature regarding the opioid epidemic in the United States and the negative consequences of opioid use disorder. We provide information regarding treatment and relapse using a variety of intervention approaches. We call for research on people with opioid use disorder that can contribute to a variety of areas: improving medication-assisted treatment, addressing chronic pain, examination of adjunctive behavioral interventions, overdose, high risk behaviors and infections, pregnancy, diverse populations, and other psychological factors. Collectively addressing these crucial areas of research will advance the field and help alleviate suffering and prevent death from opioid use disorder.

Patterns of Emotional Availability between Mothers and Young Children: Associations with Risk Factors for Borderline Personality Disorder.

Emotional availability (EA) characterizes a warm, close relationship between caregiver and child. We compared patterns (clusters) of EA on risk factors, including those for borderline personality disorder (BPD). We sampled 70 children aged 4 to 7 years from low-socioeconomic backgrounds, 51% of whose mothers had BPD. We coded filmed interactions for EA: mothers' sensitivity, structuring, non-intrusiveness, non-hostility, and children's responsiveness to, and involvement of, mothers. We additionally coded children's over-responsiveness and over-involvement. Using person-centered analyses, we identified four clusters: high-functioning, low-functioning, asynchronous (mothers above average on two of four dimensions, children below) and below average. Mothers in the low-functioning cluster had lower income, less social support, more of the borderline feature of negative relationships and more depression than did mothers in the high-functioning cluster. The children in the low-functioning group had more risk factors for BPD (physical abuse, neglect, and separation from, or loss of caregivers, and negative narrative representations of the mother-child relationship in their stories) than did children in the high-functioning group. The asynchronous group included older girls who were over-responsive and over-involving with their mothers in an apparent role reversal. Interventions targeting emotional availability may provide a buffer for children facing cumulative risks and help prevent psychopathology.

Effect of maternal borderline personality disorder on adolescents' experience of maltreatment and adolescent borderline features.

Borderline personality disorder (BPD) is a severe and chronic mental illness. Self-reported borderline features correlate highly with a diagnosis (affective instability, negative relationships, unstable sense of self, self-harm). Etiological factors of BPD include childhood maltreatment. The current study compared the experience of maltreatment in adolescent offspring of mothers with BPD, who are themselves at risk of developing the disorder, with that of offspring of mothers with no current diagnosis. Participants were 56 adolescents aged 14 to 18 years. In all, 93% of the adolescents whose mothers had BPD experienced maltreatment compared with 60% of comparisons. Specifically, adolescent offspring of mothers with BPD experienced more physical abuse, emotional abuse, and neglect, but not more sexual abuse, than did comparisons. Dimensions of maltreatment (severity, multiple subtypes, chronicity) were associated with adolescents' own total borderline features. We discuss implications for the intergenerational transmission of BPD and for clinical interventions. (PsycINFO Database Record

Maternal psychological control, maternal borderline personality disorder, and adolescent borderline features.

Linehan (1993) theorized that the experience of invalidating parenting interacts with emotional vulnerability in the development of borderline personality disorder (BPD). Parental psychological control is a type of invalidating parenting, defined as manipulation by parents of their offspring's psychological and emotional expression and experience (Barber, 1996). In a normative sample of adolescent females, adolescent-reported maternal psychological control was related to maternal borderline symptoms (Zalewski et al., 2014). The current study expanded on these findings to sample mothers with a diagnosis of BPD (n = 28) and normative comparisons (n = 28) with male and female adolescents aged 14-18. We assessed maternal and adolescent self-reported borderline features (affective instability, negative relationships, identity disturbance, and self-harm) and coded maternal psychological control from filmed problem-solving interactions. Controlling for current major depressive disorder and family income, mothers with BPD used more total psychological control with their adolescents in comparison with normative mothers. Further, maternal psychological control was positively associated with all mothers' borderline features and with adolescent affective instability. Finally, we found a significant indirect effect for maternal affective instability between maternal total psychological control and adolescent affective instability. We discuss adolescents' risk of developing BPD themselves and prevention and treatment implications. (PsycINFO Database Record

A Mother's Borderline Personality Disorder and Her Sensitivity, Autonomy Support, Hostility, Fearful/Disoriented Behavior, and Role Reversal With Her Young Child.

There is some evidence that maternal borderline personality disorder (BPD) adversely affects parenting in infancy, resulting in disorganized attachment, which longitudinally predicts BPD symptoms in adulthood. We examined parenting related to disorganized attachment beyond infancy in offspring of mothers with BPD, when parenting becomes a goal-corrected partnership. We observed puzzle solving in a low socioeconomic status (SES) sample of mothers with BPD and their children ages 4-7, n = 36, and normative comparisons, n = 34. Compared with normative mothers and controlling for maternal mood disorders, mothers with BPD were less likely to be sensitive and provide autonomy support, and were more likely to be hostile and display fearful/disoriented behavior and higher levels of parent-child role reversal. We additionally found correlations between parenting and self-reported maternal borderline features. We discuss implications for child development, including possible transmission of BPD from mothers to children via representational models, and developmentally appropriate preventive interventions.

Evidence for phase-based psychotherapy as a treatment for dissociative identity disorder comorbid with major depressive disorder and alcohol dependence.

We report on the treatment and successful outcome of a 58-year-old Native American male with a history of complex trauma presenting with dissociative identity disorder (DID) and major depressive disorder. The treatment included a trauma-informed phase-based psychotherapy as recommended by the International Society for the Study of Trauma and Dissociation for treating DID. We assessed symptoms at baseline and at three additional time points over the course of 14 months. We utilized the Reliable Change Index to examine statistically significant change in symptoms over the course of treatment. Significant symptom improvements were realized posttreatment across all measured domains of functioning, including dissociative symptoms, alcohol abuse, depression, anxiety, and emotion regulation skills. Moreover, the client no longer met criteria for DID, major depressive disorder, or alcohol abuse. Results are discussed in terms of the effectiveness of trauma-focused, phase-based treatment for DID for cases of complex trauma with comorbid disorders.

Negative Affectivity and Effortful Control in Mothers With Borderline Personality Disorder and in Their Young Children.

Research has examined temperament in individuals with borderline personality disorder (BPD) but not in their offspring, despite offspring's risk of developing BPD and the importance of temperament in the etiology of BPD. We recruited a low-socioeconomic sample of 36 mothers with BPD and their children ages 4 through 7, and 34 normative comparisons. Replicating prior studies, mothers with BPD reported themselves as having more negative affectivity (frustration, fear) and less effortful control (inhibitory control, attentional control, activation control) than did comparisons. Mothers with BPD also reported that their offspring had more negative affectivity (anger/frustration, fear) and less effortful control (inhibitory control, attentional focusing) than did comparisons. We were concerned about potential bias and shared method variance. We therefore provided validity support for mothers' ratings of their children with teacher ratings of child behavior and child self-report via their story-stem completion narratives. We discuss children's temperamental vulnerability versus differential susceptibility to the environment.

Effect of maternal autonomy and relatedness and borderline personality disorder on adolescent symptomatology.

Several theories propose a relationship between deficits in autonomy and relatedness and the development of borderline personality disorder (BPD). Empirical work supports relationships between maternal BPD and adolescent symptomatology, as well as between maternal autonomy and relatedness and adolescent symptomatology. However, no study has examined how individuals with BPD differ from normative comparisons on autonomy and relatedness, or whether mothers' BPD mediates the relationship between their autonomy and relatedness and their adolescents' symptomatology. We sampled 28 mothers with BPD and their adolescents aged 14-17 years, as well as 28 normative comparisons matched on demographic variables. We assessed BPD as a categorical diagnosis and along a continuum of self-reported borderline features. In a videotaped problem-solving interaction, controlling for current major depressive disorder, mothers with BPD were less likely to promote and more likely to inhibit relatedness, and they were marginally more likely to inhibit but equally likely to promote autonomy with their adolescents. Mothers' total borderline features mediated the relationship between mothers' promotion of autonomy plus relatedness and adolescent internalizing and externalizing symptoms (anxious depression, withdrawn depression, somatic problems, rule breaking, and aggression) and adolescent borderline features (affective instability and self-harm). Mothers' total borderline features also mediated the relationship between mothers' inhibition of autonomy plus relatedness and adolescent internalizing and externalizing symptoms (anxious depression, withdrawn depression, somatic problems, and aggression but not rule breaking) and adolescent borderline features (affective instability and self-harm). We discuss findings in terms of light shed on BPD and the effect of maternal BPD on adolescent development.

Mothers with borderline personality and their young children: Adult Attachment Interviews, mother-child interactions, and children's narrative representations.

Borderline personality disorder (BPD) involves disruptions in attachment, self, and self-regulation, domains conceptually similar to developmental tasks of early childhood. Because offspring of mothers with BPD are at elevated risk of developing BPD themselves (White, Gunderson, Zanarini, & Hudson, 2003), studying them may inform precursors to BPD. We sampled 31 children age 4-7 whose mothers have BPD and 31 normative comparisons. We examined relationships between mothers' Adult Attachment Interview (AAI) representations (George, Kaplan, & Main, 1984), mothers' observed parenting, and children's narrative representations. Replicating previous studies, mothers with BPD were more likely to be classified as preoccupied and unresolved on the AAI. In a larger sample, which included the current one, we also replicated two underlying AAI dimensions found in normative samples (Roisman, Fraley, & Belsky, 2007; Whipple, Bernier, & Mageau, 2011). Controlling for current mood, anxiety, and other personality disorders, mothers with BPD were significantly higher than were comparisons on the preoccupied/unresolved, but not the dismissive, dimension. Children's narrative representations relevant to disruptions in attachment (fear of abandonment and role reversal), self (incongruent child and self/fantasy confusion), and self-regulation (destruction of objects) were significantly correlated with the preoccupied/unresolved, but not the dismissive, dimension. Furthermore, mothers' parenting significantly mediated the relationship between the preoccupied/unresolved dimension and their children's narrative representations of fear of abandonment.

Do mothers with borderline personality disorder oscillate in their behavior towards their children? Implications for interventions: commentary on Stepp, Whalen, Pilkonis, Hipwell, and Levine's article "Children of mothers with borderline personality disorder: identifying parenting behaviors as potential targets for intervention".

Comments on an article Children of mothers with borderline personality disorder: Identifying parenting behaviors as potential targets for intervention by Stepp, Whalen, Pilkonis, Hipwell, and Levine (see record 2011-05873-001). Maternal borderline personality disorder (BPD) may present a challenge for children's development (Macfie, 2009). Although the fertility rate for women with BPD is relatively low (McGlashan, 1986; Stone, 1990), BPD affects women exclusively during their childbearing years: from adolescence (Ludolph et al., 1990) through middle age (Paris, 1993). Stepp and her colleagues provide a rich introduction to the need for interventions for offspring of women with BPD. They also provide a wide range of suggestions.

Representations of the caregiver-child relationship and of the self, and emotion regulation in the narratives of young children whose mothers have borderline personality disorder.

Borderline personality disorder (BPD) represents a severe distortion in the development of attachment, self, and emotion regulation. Study of children at high risk of developing BPD may inform precursors to BPD. In a low socioeconomic status sample of 30 children aged 4-7 whose mothers have BPD and 30 normative comparisons, representations of the caregiver-child relationship and of the self, and emotion regulation were assessed with a story-stem completion measure. In contrast to comparisons and controlling for major depressive disorder, children whose mothers have BPD told stories with the following: (a) more parent-child role reversal, more fear of abandonment, and more negative mother-child and father-child relationship expectations; (b) more incongruent and shameful representations of the self; and (c) poorer emotion regulation indicated by more confusion of boundaries between fantasy and reality and between self and fantasy, more fantasy proneness, less narrative coherence, and marginally more intrusion of traumatic themes. In the sample as a whole, (a) a maladaptive caregiver-child relationship composite was associated with maternal identity disturbance and self-harm; (b) a maladaptive self-composite was associated with maternal self-harm; and (c) a maladaptive emotion regulation composite was associated with maternal identity disturbance, negative relationships, and self-harm. Results are discussed in terms of putative precursors to BPD and preventive interventions.

Development in Children and Adolescents Whose Mothers Have Borderline Personality Disorder.

A mother's mental illness may have a profound effect on her child's development, including an increased risk of the child developing the same disorder. From a developmental psychopathology perspective, offspring provide an opportunity to examine pathways to disorder versus resilience. Borderline personality disorder (BPD) is a severe disorder diagnosed in early adulthood involving stormy relationships, an unstable sense of identity, and self-destructive behavior. Interestingly, the domains of dysfunction are conceptually similar to developmental tasks in early childhood reworked in adolescence: attachment, self development, and self-regulation. Early deviation may increase the risk for later disorder. There are five empirical studies of children whose mothers have BPD, two conducted from a developmental perspective. This article proposes a theoretical framework and an innovative methodology with which to extend this research, and suggests an intervention to bring development back on track if necessary.