boderline personality disorder and parenting

what is bpd also known as and problems with names

• emotionally unstable personality disorder 

• Can be a certain element of stigma with personality disorders - personalities are who you are, so labelling it as being disordered can feel bad 

• EUPD is more informative but may not be better than bpd as the condition has more stigma associated with it 

• DSM refers to it as BPD, WHO refers to it as EUPD

origin of the name of bpd

• Means when some patients came in, psychiatrists saw signs of neurosis, psychosis, schizophrenia but not those completely - on the borderline of these conditions 

potential causes of bpd

• Really complex condition - lots of comorbidity 

• Childhood trauma eg sexual abuse, adversity (Paris, 2008)

Developmental precursors

• Temperament, less stable/settles, more irritability, predisposition for impulsivity (Bozzatello, 2019)

• Maladaptive parenting (Johnson, 2006; Paris, 2003) leads on to 

invalidating environment as a cause of bpd

• SES seems to create extra issues, parental mental illness, substance misuse (Stepp, 2016; White, 2003)

• Brain differences (Mauchnik, 2005) prefrontal cortex less well developed and activated - difficulties with self-control, impulsivity. hippocampus has less grey matter (involved in memory) more activity in the amygdala - processes emotions, fear, anger, sadness

• Hereditary (Zanarini, 2004), almost 50% is genetic, may not mean that genetically if you are predisposed to BPD you will develop the condition, also involves environment

• Contemporary theories: biosocial model (Linehan 1993; Crowell 2009) have an interaction. Eg genetically may be predisposed to this condition, may also have temperament that predisposes you even more to have it, could then have other environmental issues going on that exacerbate it

biosocial model of bpd

• All of these factors are made worse by the overarching invalidating environment 

  If had sensitive parenting trajectory might not happen - may give coping strategies etc

  
  

who does it affect

• 1-6% of general population, chances are its higher, people aren't diagnosed 

• 10% psychiatric outpatients and 20% inpatients have BPD

• More prevalent than schizophrenia and bi-polar disorder together 

• Some studies show equal male/female prevalence

• Females experience greater symptoms (more emotional, may then lead to self-harm) and more likely to be seen in clinical settings, men have more angry symptoms 

• Many misdiagnosed or remain undiagnosed eg bipolar, depression, ptsd although maybe not misdiagnosis to a point, childhood traumas that have been experienced act in a very similar way to ptsd

• Typically diagnosed in late adolescence/early adulthood, impulsivity may lead to having children at quite an early age which may lead to issues with parenting 

long term outcome (prognosis)

• Possible to recover and treat

• 70% will attempt suicide at some point 

• High rate of mortality – death by suicide 50 x general population, 8-10% complete attempt, dont want to end life, just dont know what they can do in order to live their life

• Self-harm high – c.75% way of communicating level of despair, release tension and pressure that has built and built 

• Remission possible – Gunderson (2011), 85% remitted over 10 years; Paris (2011), 92% no longer met diagnostic criteria after 27 years

• Remission more likely in those with higher IQ, functioning adequately at work, with a stable relationship, and not frequently hospitalised

• Impulsivity first to remit, ED slower, relationship difficulties remain - could be due to the effects of ED

Co-occurring conditions 

• Anxiety disorders

• Post traumatic stress disorder (PTSD)

• ADHD

• Substance misuse

• Eating disorders

• Other personality disorders, quite often an overlap between conditions

• Mood disorders/depressive disorders - 83% lifetime prevalence of major depressive disorder (Zanarini et al., 1998), very common to co-exist 

BPD diagnostic criteria (DSM-5)

Lots go hand in hand with each other - interconnected

• 5 out of 9 present for diagnosis - heterogeneous condition, may have first 5 or last 5 etc, some people might have all 9

Living with BPD

Very impulsive - dont have a sense of identity dye hair to reinvent herself - lack of sense of self 

Scared people are going to leave eg boyfriend, friends  - can be real or imagined. Fear is very strong - leads to pushing away or being really clingy

Black and white thinking - love one of their friends, if they don't text back can go to hating them. Feeling is so intense. Stew on it all day. Don't integrate the whole person - good friend when doing something they're happy with, bad person when they do something slightly wrong 

0-100 - have a good day, something happens then ruined for the whole day. Very intense compared to bi-polar as just one word can ruin the day

examples of optimal parenting

• sensitive, responsive

• afectionate, warm

• encouraging autonomy

• supportive

• guiding, scaffolding

• regulating beh

• emotional availability

• safety, security

• physical care

still face experiment

• Sat in front of the child, engage in normal way, smiles, looks where pointing etc

• Mother is told to stop playing with the child and have an expressionless face 

• Child tries to get mother to engage 

• Quickly becomes distressed - has made such a difference 

attachment

• Bowlby’s attachment theory – motivational system for establishing attachment to primary caregiver

• Ensures survival of infant – attachment figure as secure base for exploration and support in times of stress. Eg can explore new places as know they have a secure base to come back to

• Believes parent and child are built with predispositions for this, caregiver wants to care for the child, child has social releasers that help parents to attach

ainsworth’s attachment categories

How might having a diagnosis of BPD make parenting difficult?

• Anger is not good around a child

• Insecure attachment 

• Lack of independence for child - need to let child be more autonomous but scared of abandonment 

• When a baby is born, they split. Good mum feeds me, bad mum leaves me to cry. Over time have this cycle, when child has a need, mother responds sensitively to that need. Eventually learns mother will come. If that cycle doesn’t come or is interrupted, have potential difficulties. Process allows them to bring the two together, the reason people with BPD split is because they haven’t had that emotional support when they are younger 

• Start of splitting between good mother and bad mother haven't had that emotional support when they were younger 

• Struggles with emotional dysregulation - child is born dysregulated - role as primary caregiver is to help regulate their emotions so very difficult to do this

parenting beh of mothers with bpd

• some van parent very well, others maladaptive

maladaptive parenting in bpd

• Less sensitive (e.g., Crandell et al., 2003)

• Overprotective, intrusive, overinvolvement (e.g. Elliot et al., 2014) coming from a place of wanting to care for child as often experienced issues when they were younger 

• More hostile (e.g., Newman et al., 2007)

• Less engagement, rejection (Hobson et al., 2009; Reinelt et al., 2014), less involved 

• Maladaptive interactions (e.g., Macfie et al., 2014) role reversal (child becomes the parent), withdrawn, inhibiting autonomy

other parenting characteristics

• No difference from controls on maternal warmth (e.g., Herr et al., 2008) not someone who doesn't want to care for child, really want to care but have difficulties 

• Inconsistent parenting (Stepp et al., 2012, Eyden et al., in prep) do same thing but sometimes get 

• Maternal distress (Dittrich et al., 2020)

5-year-old child of a mother with BPD (Macfie, 2009)

• Story-stem completion task, depict story, let child play, act out or say something with that story 

• Researcher tells a story of a birthday party using family dolls and a cake, then asks the child: "Show me and tell me what happens now"

• The girl tells of how presents are opened, and the family eats cake

• She then adds: "and then mum takes off her clothes and gets drunk"

• Mother acts inappropriately - child thinks this is the norm at a birthday party

15-year-old daughter of mother with BPD (Macfie, 2009)

• D: Now you’re acting even younger. You’re giggly and weird​

• M: Oh well, that’s just because I’m being rebellious at the moment. I want to try to have fun.​

• D: I’m the teenager I’m supposed to do that.​

• M: It has been so long since I’ve had fun and done the things that I want to do. Yeah, I miss being a teenager. It’d be nice if we could have that little bit of experience together and have fun.​

• D: No, you’re supposed to be my Mom.​

• M: Well, maybe someday I can be your Mom again​

• D: By the time you’re my Mom, I’ll be an adult, so it won’t even matter. 

• Mother acting more like teenager, teenager acting like the adults, teen may even start having to care for the mum

Parenting knowledge of mothers with BPD (Eyden et al., 2023)

• Do mothers with BPD know what 'good' parenting looks like?

• 26 BPD mothers, 25 depressed, 25 no mental illness

• Q-sort task on 'ideal' parenting

• Ranked 90 behaviours - best possible beh to worst beh

• No difference between groups with parenting knowledge

Parenting self-efficacy of mothers with BPD (Eyden et al., 2023)

• Do mothers with BPD think they are good at parenting?

• 26 BPD mothers, 25 depressed, 25 no mental illness

• Questionnaire parenting self-efficacy

• BPD and depression lower on perceived parenting efficacy

• Symptom severity predicted parenting self-efficacy, negative correlation

Are BPD mothers emotionally available to child? Eyden et al., (in prep)

• Emotional Availability - open dyadic communication, available for play, communication etc. encompasses lots of parenting domains you’d want to look at  

• Assessed via observations (mother and child playing) and EAS coded

• 25 BPD, 25 depression, 25 no mental illness. Difficult to do research in this area as have to build lots of trust to film interactions and do research, feel they’d be judged, heightened sensitivity  

• More intrusive and overprotective

• Less sensitive, more hostile only prevalent for those with BPD 

• Mental health severity predictor for maternal EA

• Maternal sensitivity predicted child EA. if can be more sensitive, could improve child’s emotional availability 

emotional availability categories of mother and child

Key links to attachment categories 

Depression - 50% are high in emotional availability, other 50% are the other categories 

BPD - high in complicated attachment 

With depression, times there would be a slight mismatch which is complicated, when a mum acts in a certain way, delay in how the child is reacting, or delay in the way the mum is responding to the child

When look at children’s emotional availability, don’t mirror

With BPD - fewer in the complicated category, more of them starting to withdraw. Dont know how the mum is going to react in this situation so they just shut up

Outcomes for offspring of mothers with BPD Eyden et al., (2016)

• Higher levels of BPD symptoms-especially emotional dysregulation (e.g., Macfie et al., 2014)

• Higher levels of general psychopathology (depression common) (Barnow et al., 2013)

• Higher internalising/externalising problems (eg rumination/behavioural problems such as aggressiveness) (e.g., Barnow et al., 2006) lots of acting out beh - act out for attention, way of dealing with inconsistencies 

• Psychosocial difficulties (Abela et al., 2005; Barnow et al., 2006) effects on self-esteem, self-critical 

• Poorer executive function (Zalewski et al., 2018)

• Interpersonal difficulties (withdrawn/dysfunctional mother-child interactions) (e.g., Schacht et al., 2013) if having difficulty with emotions harder to make friends 

• More likely to be categorised as insecurely attached (Gratz et al., 2014)

• Higher family instability (Feldman et al., 1995) have more frequent moves, more MH within parent, more likely to have sibling or relative that has gone to prison

Mechanisms of transmission of vulnerability 

• Clearly a relationship between mother’s vulnerability and child’s vulnerability - is there something that is mediating this (instead of a direct relationship)

• Some heritability: .40, so ~40% of individual differences in BPD symptoms attributable to genetics in some way

• Offspring of BPD mothers may be more likely to experience childhood adversity/trauma

• Maternal emotional dysfunction mediates mother-child association

• Maladaptive parenting (insensitive, rejecting, hostile) as mediator, inconsistent, rejective, hostile parenting 

• Biosocial developmental model – inherited vulnerability to impulsivity interacts with environmental risk factors 

• If have invalidating environment on top of all of this, adds to problems

Child vulnerability

Factors affecting impact of parental mental illness

Timing of episode(s)

• Effects on parenting and child strongest when symptoms are current

• Depends on developmental stage of child, strongest in 1st year, most important part for relationship between parent and child

• Chronicity and severity of mental illness

• Child’s own temperament (positive and negative)

• Associated with inter-parental conflict

• Could explain rise in externalising problems in children 

• Parental depression leads to child depression - interparental discord then has an impact on conduct problems, if there is lots of rowing going on you want attention - may lead to this attention seeking conduct beh 

buffers

• Not all children go on to develop these outcomes 

• Social support for mother eg friends help with babysitting. Tend to be single mothers so social support is very important 

• ‘Secondary parents’ – father, grandparent, mother’s friends, aunt etc.

• Siblings and friends

• Secure attachment (could be with another person)

• Higher IQ, positive personality traits

• More resourceful, better coping strategies (Rutter et al., 2012) resilience - children go through intense difficulties and function normally - what is it about them that is different

Interventions for individuals with BPD

• Dialectical Behaviour Therapy (DBT) (Linehan, 1993; 2014) one of the best ones, individual and group therapy, based on cbt. Ways you can influence and change beh, distress tolerance, emotional regulation etc

• Mentalization-Based Therapy (MBT) (Bateman & Fonagy, 1999; 2009) examine own thoughts and beliefs, change them, manage emotions and relationships, important to have a good client-therapist relationship  

• Schema-Focussed Therapy (Young, 1994), explores maladaptive early schemas eg self-depleting, replace with more positive ones 

• Other recognised therapies e.g., Systems Training for Emotional Predictability & Problem Solving (Blum et al., 2002; 2004); General Psychiatric Management (Gunderson & Links, 2014) some are shorter therapies - fairly effective but difficulties when therapy stops. Good for early intervention

Parenting interventions for mothers with BPD

• General parenting programmes e.g., Confident Parents (Mouton et al., 2018); Triple P Positive Parenting Programme (Sanders 1999); Watch, Wait & Wonder (Muir et al., 1999) but difficult because follow childs lead, wait for them to do something (overly involved with child so need to help them with that first)

• Project Air Parenting with Personality Disorder and Complex Mental Health Issues (McCarthy et al., 2015). How to care for yourself as well as others, deal with children at all ages. Also talk to children so they can start to understand 

• Parenting Skills for Mothers with Borderline Personality Disorder (Rosenbach et al., 2020). Echoes a lot of the deficits in the emotional availability study. What is developmentally appropriate for the child. Emotional regulation and conflict resolution.  

• Perinatal emotional skills group for BPD (Moran el al., 2024). Mother-infant DBT, try to understand how the child is feeling 

• Measures of parenting intervention efficacy

Barriers to intervention 

Practical

• Caught up with being a mother, where to put child when in therapy 

• Disorganised, may be late to appointments

Engagement

• Drop-out rates high

• Treatment completion varies 36-100%

• Many studies DBT – bias? Mostly talk about DBT studies which people tend to engage better with 

Behavioural

• Impulsivity – distracted by other tasks

• Challenging behaviours with therapist/psychiatrist. Almost want to test whether the therapist will leave them, pushes boundaries. Becuase of sensitivity, constantly want reassurance 

• Lack of commitment to change

Fear

• Being judged

• Child being removed

Overcoming barriers to intervention 

Ideal model of intervention 

Don't often get all of it, not looked at it as a holistic thing

• Initially - have DBT or MBT, helps you manage your symptoms. When can manage symptoms effectively, allows you to engage with other therapies 

• 2 - aware of the things, scaffold and guide through

• 3 - then have individual parenting support. Record playing with the child and play it back to them. What could they have done differently. 

• 4 - how to continue support, as go through life stages way you need to parent adapts - how to do this

• Whilst this is happening have family support so the people around them know what they’re dealing with/going through

why is bpd important to research

• Impact on parenting 

• Impact on child

• Prevalence c.6% of general population

• Female gender bias in clinical setting

• Onset age: late adolescence/early adulthood

• Need for early intervention

Implications for research 

• What are the ethical considerations? What is appropriate, safeguarding for both the researcher and mother. How to protect mother when asking about childhood and parenting etc 

• Potential recruitment difficulties? Don't want to be observed/asked about parenting. Also very likely to have high drop out rates 

• Methodological design considerations? Have children of dif ages, large range. How do you come up with a method suitable for all of them. Then how do you compare