Borderline personality disorder and infants: interrupting intergenerational cycles of despair

1. Borderline personality disorder and infants: interrupting intergenerational cycles of despair Anne Sved Williams Director of Perinatal and Infant Mental Health Services, WCHN, Adelaide, and Medical Unit Head Helen Mayo House Clinical Senior Lecturer, University of Adelaide Anne.SvedWilliams@health.sa.gov.au

2. This morning: Background • What is borderline personality disorder (BPD) • What causes BPD? • What problems does can be caused for infants of mothers with BPD • What problems does can be caused for children and adults when mother has BPD • What is happening at the brain level in BPD • What thinking styles prevail in BPD • Overview of how the intergenerational cycles can be disrupted and new styles learned for mother and infant? Beginning with the BPD diagnosis

3. Some generalities which guide my thinking • All parents are doing the best they can • Mostly it’s “good-enough” albeit not perfect • We work best by enhancing what is working well (and clarifying what isnt working IF POSSIBLE) • Sometimes it’s not good enough and we need to invoke another system which tries to be good-enough – child protection services • “Early intervention” – in the perinatal period either antenatal or postnatal – NOT in adolescence!

4. SOME POINTS OF REFLECTION • GIVE A MAN (OR WOMAN) A HAMMER AND EVERYTHING (S)HE SEES ARE NAILS • IS WHAT WE DO OLD HAT OR SOMETHING NEW? Clinical Practice Guideline for the Management of Borderline Personality Disorder (2012) Louise Newman et ahttp://www.nhmrc.gov.au/guidelines/publications/mh25 • AND IS IT A DROP IN THE OCEAN OR A MOMENT OF EXCITEMENT (CF MOMENTS OF MEETING) • WE HAVE JUST FAMILIARISED THE WORLD WITH PND – IS IT A MISTAKE TO TALK ABOUT BPD? • And what does that strange name mean? Border line??

5. Why is it called BORDERLINE personality disorder? • Borderline between psychosis and neurosis (Otto Kernberg, 1960s)

6. WHAT IS BPD?A VERY BRIEF REVIEW • In essence, emotional dysregulation with its behavioural consequences underpinned by changes at the brain level • 9 Characteristics as defined in DSM IV • “They love without measure those whom they will soon hate without reason.” Thomas Sydenham, The Whole Works of That Excellent Practical Physician, Dr. Thomas Sydenham • And now: (please turn away NOW if you don’t like swearing…)

7. What is BPD (DSM IV & V) • frantic efforts to avoid real or imagined abandonment • a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.  • identity disturbance: markedly and persistently unstable self-image or sense of self.  • impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) • recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior • affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).  • chronic feelings of emptiness  • inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)  • transient, stress-related paranoid ideation or severe dissociative symptoms

8. WHAT CAUSES BPD? • TRADITIONALLY: SEVERE CHILDHOOD ABUSE OF ALL SORTS: EMOTIONAL, VERBAL, SEXUAL, PHYSICAL • INTERGENERATIONAL TRANSFER OF PROBLEMS FROM MOTHER WHO IS FRIGHTENED AND FRIGHTENING (Mary Main and Eric Hesse) • MORE RECENTLY: EXQUISITE SENSITIVITY (PROBABLY GENETIC) TO INVALIDATING STYLES OF PARENTING • IN THE VIEWS OF GRANDPARENTS. IT JUST HAPPENED – OR GENETICS ALONE

9. WHY research and look at different pathways for BPD? 1 It’s common: a look at incidence 2 It causes multiple problems for a woman, her infant and her family 3 Troubling behaviours so staff find it hard to manage BPD 4 Few treatment pathways until “recently” Stigma has intruded greatly in moving treatment pathways forward: “JUST A PD! – but don’t let the patient know” “A MASSIVE PD = absolutely nothing can be done and watch out!” Ie lots of problems for families AND staff

10. INCIDENCE • PND – 15% of postnatal women • BPD: 1-6% of the population • 12- 20% of all inpatient psychiatric units in international literature • 50% of Helen Mayo House patients (25% with full diagnosis, 25% with traits of that condition which tend to improve during inpatient stay) • THIS WAS PHASE ONE OF OUR RESEARCH: AT ADMISSION AND DISCHARGE: EPDS, BECK, MCLEAN, MPAS (Condon) + Clinical interviews

11. Research into BPD v PNDPubMed search is revealing -June 2014 • Perinatal depression 1482 • PND AND infant 512 • Assume PND is 15 x more common than BPD should be • BPD perinatal 100 (ieapprox 1500/15) • AND infant 34 (512/15) • Perinatal borderline personality disorder 10 • Perinatal BPD AND infant 5 • Plenty in literature about trauma butthat is not 1:1 equivalent to BPD

12. What attachment style do women with BPD have? – Agrawal (2004) • Strong association between BPD and insecure attachment • Unresolved, preoccupied and fearful • A longing for intimacy combined with concerns about dependency and rejection • And of course we know that intergenerational transfer of attachment styles is the norm

13. PROBLEMS CAUSED:What happens to the infants • Kiel (2011): mothers initially sensitive but sensitivity decreases, infant cries longer • Steele and Siever (2010): mothers are frightened and frightening: infants develop disorganised attachment, mother preoccupied with past losses, mourning • Hobson and Crandell (2005): mothers intrusively insensitive, infants have poorer behaviouralorganisation, interact less well w strangers

14. PROBLEMS CAUSED:Child and young adult outcomes • S. Stepp (2011): a large number of internalising and externalisingbehaviours • Winsper (2012): 11 yr olds: cognitive deficits, parental conflict • Lyons Ruth (2012, 2013): BPD intergenerational transfer of problems especially with maternal avoidance

15. And Louise Newman (2011) • Neurobiological basis established from animal studies, human observation, fMRI • Development of infant regulatory systems influenced by parenting • Frontolimbic regulatory pathways implicated in parental response to infant cues • So a look at brain pathways

16. Hindbrain Basic life function Midbrain: Emotions Memory Movement Forebrain: Thinking

17. Hindbrain Basic life function Midbrain: Emotions Memory Movement Forebrain: Thinking

18. INFANT MOTHER

19. INFANT MOTHER

20. INFANT MOTHER

21. INFANT MOTHER

22. INFANT MOTHER

23. INFANT MOTHER

24. INFANT MOTHER

25. INFANT MOTHER

26. INFANT MOTHER Adrenal gland

27. INFANT MOTHER Adrenal gland

29. WE CAN ONLY THINK WITH OUR FOREBRAIN AND EMOTE WITH OUR MIDBRAINS. WHEN WE ARE EMOTING, WE ARE BASICALLY NOT THINKING (CLEARLY) SO WHEN A MOTHER HAS HER OWN PROBLEMS AND THE INFANT’S CRIES TRIGGER OFF HER MIDBRAIN, SHE IS “IN”HER MIDBRAIN AND WILL FIND IT HARD TO THINK. SO PROBLEMS WILL ARISE

30. INFANT MOTHER

31. INFANT MOTHER

32. INFANT MOTHER

33. INFANT MOTHER Adrenal gland

34. Infant Mother Grandmother

36. So diagnosing BPD rather than PND PND has become a relatively accepted diagnosis with known pathways to care – “I’ve got the postnatals” BPD: mood problems +

37. The overlap EMTIONAL DYSREGULATION

38. Advantages of moving from PND to BPD diagnosis? • Different use of medications • Tackling the problem in a different way • Still some stigma and some special meanings with both conditions – particularly amongst health professionals • If squeamish about BPD diagnosis, emphasise as we do the “traits” of BPD – “you have a touch of BPD” • It is another TLA to play around with

39. Why is BPD common in our MBU? • Referrers know we don’t run away from that diagnosis and patients with that diagnosis do well • Our children are older than infants in most MBUs as we take children to the age of 3 years • We look for it and recognise how it is “uncovered” by that crying infant in women who are otherwise functional – and by recognising it we do better with helping them

40. So to intervene in the intergenerational transfer of BPD • Have to move to a mindset that open diagnosis of BPD is OK • Clarity with the woman (and family) about the diagnosis and psychoeducation • A mode to help her with herself • A mode to help her with her baby • Likely to involve helping the woman calm herself and then to reflect

41. Maternal Calming Infant Mother Grandmother

42. Maternal Calming AND ENHANCING MATERNAL REFLECTIVE CAPACITY Infant Mother Grandmother

43. Maternal Calming AND ENHANCING MATERNAL REFLECTIVE CAPACITY Infant Mother Grandmother

44. Reflective Functioning (RF) and Mentalising • Mentalising: Implicitly and explicitly interpreting the actions of oneself and other as meaningful on the basis of intentional mental states (e.g., desires, needs, feelings, beliefs, & reasons) • “To see ourselves from the outside and others from the inside” • Mentalising is the capacity to envision states – reflective functioning is the behaviour of mentalising

45. Reflective Functioning and relevance to BPD and infants • RF (Fonagy, Steele, Steele, Bateman, Target ): the ability of parents to reflect on their own parents’ effects on themselves (as in the Adult Attachment Interview – AAI) “my mother was always depressed so she wasn’t there for me and that makes it hard for me with my baby” • Parental reflective functioning: (Arietta Slade): the ability of parents to reflect on their child’s internal states and the effects of their own behaviours on the child – the awareness that a child HAS internal states “She is having a tantrum today as she is anxious because she has seen the suitcases being packed”

46. Troubled Parental Reflective Functioning • “that baby is having a temper tantrum to get at me”

47. Can RF or PRF be taught? • Yes, but only when the mother is in a calm enough state of mind

48. Thinking styles in mentalisation based therapy (MBT) • Psychic equivalence: “Concrete- my thoughts are real”, mind-world isomorphism – mental reality = outer reality. “as I am that bad, I only deserve to die/kill myself” • Pretend mode (fake it till you make it…) – ideas form no bridge between inner and outer reality • Teleological stance: behaviour/physical change in self/others necessary: Only action that has physical impact is felt to be able to alter mental state in both self and other egManipulative physical acts (self-harm) or Demand for acts of demonstration (of affection) by others • www.ucl.ac.uk/psychoanalysis/unit-staff/staff.htm (Bateman reference)

49. ValidatingAcknowledging, confirming Validation: To child: “Oh you poor thing, you fell over and hurt yourself. Let me see? Oh a bandaid will help I think” To mother: “yes I know you are upset. Can I help with something” Invalidation: To child:“Its only a scratch. Don’t be a sook” To mother: “it’s only a baby crying – why are you so upset (hopeless)”

50. How we work now with women with BPD and their infants • Early diagnosis of BPD • Psychoeducation for the woman AND her partner AND her Family of Origin (?!) • Ward protocol engaged • Reflective supervision for staff • Much treatment as usual eg COS, MarteMeo, interactional guidance and the biopsychosocial approach and systems issues • Validating MAR’S WAILS • Usual protocol at discharge AND referral to our research DBT group which involves therapy for the woman and then her relationship with her infant