3a
Jenny Macfie, Samantha K. Noose, and Andrea M. Gorrondona
Turner and colleagues have written a thoughtful and comprehensive overview of theory and research across a vast literature: environmental and sociocultural influences on the development of personality disorders (PDs). They review behavioral genetics studies and studies on the prevalence of PDs in different countries and from different socioeconomic backgrounds. They describe a wide variety of theories of how PDs develop, and review environmental risk factors from early childhood adversity to the quality of communities. Our commentary, focusing on borderline PD (for which there is the most research), extends this work in two ways. First, we propose an overarching theory of environmental and sociocultural influences on the development of PDs. Second, we add empirical support for two of the theories that Turner and colleagues present: attachment and biosocial theories. In this way, we aim to identify processes underlying the development of PDs that may be the focus of interventions.
Ecological Systems Theory
Maladaptive and inflexible patterns of behavior, thinking, and inner experience that endure over time characterize PDs (American Psychiatric Association, 2013). Although we do not diagnose PDs until adolescence or early adulthood, they have their origins much earlier. The authors report findings from behavioral genetics studies of twins that derive a percentage for how much genes versus the environment contribute to the development of PDs. As they point out, genes are important, a unique environment is important, and a shared environment (e.g., by siblings) is less so. However, the behavioral genetics model has limitations as a developmental theory because it sets up an artificial dichotomy between nature and nurture. Development results from a relationship between the environment and genes, rather than from the two components separately. This relationship consists of ongoing bi-directional influences across levels of analysis: genetic activity, neural activity, behavior, and the environment (Gottlieb, 2003; Gottlieb & Halpern, 2002; Gottlieb & Lickliter, 2007).
A developmental theory that encompasses the breadth of environmental and sociocultural influences on the development of PDs and the importance of bi-directional interactions is Bronfenbrenner’s ecological systems theory (Bronfenbrenner, 1979). Bronfenbrenner proposes that, to understand child development, we need to examine the contexts within which it occurs. The child and his or her biology/genetic predispositions interact directly with proximal influences (e.g., caregivers, siblings, schools), which are themselves influenced by more distal factors (e.g., economic, political, sociocultural). As the authors note, current evidence suggests that proximal environmental influences are more significant than more distal sociocultural influences. We therefore turn to empirical evidence in support of interactions between the child and his or her caregiving environment proposed by attachment and biosocial theories.
The Role of Representational Models Linking Early Caregiving to the Development of PDs
As Turner and colleagues report, attachment theory posits that mental representations of self and other, termed internal working models, develop in the context of the infant–caregiver relationship and are carried forward to inform future relationships (Bowlby, 1973). Thus, a secure attachment developed in infancy with a primary caregiver resulting from sensitive and responsive care is thought to result in representations of the self as worthy of care and others as trustworthy. Disorganized infant attachment, on the other hand, results from maltreatment by caregivers or from caregivers who have suffered recent losses of their own attachment figures (Barnett, Ganiban, & Cicchetti, 1999; van Ijzendoorn, Schuengel, & Bakermans-Kranenburg, 1999). Disorganized attachment may disrupt the development of representations of self and other. For example, both a child’s experience of trauma (including maltreatment) and the attachment figure’s experience of a loss within two years of the child’s birth predicted borderline PD (Liotti & Pasquini, 2000). When an infant is frightened by his or her caregiver or sees the caregiver frightened him or herself due to having experienced a recent loss, the infant has nowhere to turn for comfort or to soothe distress. There is no strategy that the infant can employ to cope: expressing attachment needs directly (secure attachment), exaggerating them (anxious-resistant attachment), or minimizing them (avoidant attachment) does not make it more likely that the caregiver will respond to the infant’s distress. Approach/avoidance motivations towards the caregiver collide, leaving the infant frozen in distress, unsoothed, dissociated, and dysregulated (Main & Solomon, 1990).
What is the empirical evidence in support of mental representations or internal working models derived from the infant–caregiver relationship in the development of PDs? In a sample of first time mothers at high risk due to poverty, with most being single parents, disorganized infant–mother attachment at 12–18 months was associated with the development of borderline PD symptoms in early adulthood (Carlson, Egeland, & Sroufe, 2009). Moreover, disturbed representations of the self, coded from children’s narratives at ages 8 and 12 (e.g., involving intrusive violence, unresolved guilt or fear, bizarre images related to the self), mediated this relationship. Findings thus support an interaction between the environment in the form of caregiving and the child’s representations of self and other in the development of a PD (Carlson et al., 2009).
Moreover, a second study using the same sample found that social behavior and representations of relationships (assessed three times between childhood and adolescence) mediated the relationship between early caregiving quality (including disorganized attachment at 12–18 months and observations of parenting at 12–42 months) and PD symptoms at age 28. Furthermore, there were significant interactive pathways between children’s representations and their behavior over time. Thus, children’s representations affected their behavior and vice versa, and both mediated the relationship between early caregiving and PD symptoms in adulthood (Carlson & Ruiz, 2016). These findings extend evidence for a relationship between the child’s mental representations and the environment from borderline PD to PDs more generally.
The Role of Biology Linking Early Caregiving to the Development of PDs
The authors also propose Linehan’s biosocial theory to describe how the environment might influence the development of PDs, specifically borderline PD. The biosocial theory posits that emotion dysregulation is developed and maintained by the interaction between an individual’s biological predispositions (e.g., emotional reactivity, trait impulsivity) and invalidating environments that prevent a child from learning how to respond adaptively to strong emotions (Crowell, Beauchaine, & Linehan, 2009; Linehan, 1993). In the longitudinal study reviewed above (Carlson et al., 2009), both temperamental (e.g., emotionality at 30 months, infant activity at 6 months) and environmental factors (e.g., maltreatment from 12–18 months, disorganized attachment at 12–18 months, maternal hostility at 42 months, maternal life stress from 3 to 42 months, and family/father disruption from 1 to 18 years) were associated with borderline PD symptoms in early adulthood. However, this study did not test interactions between temperamental and environmental factors.
One line of research that has examined the interaction between temperament (i.e., emotional reactivity) and environment in the development of borderline PD is Stepp and colleagues’ research on adolescent girls. For example, Stepp and colleagues (Stepp, Scott, Jones, Whalen, and Hipwell, 2016) found that mother-reported family adversity predicted an increase in girls’ borderline PD symptoms from age 16 to 18, and strengthened the relationship between girls’ negative emotional reactivity during a conflict discussion task with their mothers and the girls’ borderline PD symptoms (Stepp et al., 2016). Furthermore, using the same sample, Dixon-Gordon and colleagues (Dixon-Gordon, Whalen, Scott, Cummins, & Stepp, 2016) found a stronger association between girls’ negative emotional reactivity and borderline PD symptom severity when high maternal problem-solving during the conflict discussion task was combined with low maternal support/validation. Conversely, when high maternal problem-solving was combined with high levels of support/validation during this task, the relationship between girls’ negative emotional reactivity and borderline PD symptoms was significantly reduced (Dixon-Gordon et al., 2016). These findings suggest that maternal skill at problem-solving is not sufficient for buffering the potential negative consequences of emotional reactivity among adolescent girls. Rather, mothers (or other primary caregivers) need to combine problem-solving with support, sensitivity, and validation of their adolescents’ distress. Notably, biological data support these results. Specifically, when the girls listened to audio recordings of their mothers criticizing, praising, or giving neutral feedback, greater pupillary reactivity in response to maternal criticism predicted increasing levels of borderline PD symptoms over the 18-month period. Alternatively, lower pupillary reactivity predicted more rapid improvement of borderline PD symptoms over the same 18-month period (Scott, Zalewski, Beeney, Jones, & Stepp, 2017). These findings further demonstrate the relevance of both a temperamental emotional vulnerability and an invalidating environment in the development of borderline PD.
Implications for Interventions
There are several effective treatments for PDs that flow from environmental theories as noted by Turner et al. (Bateman & Fonagy, 2001, 2008; Levy et al., 2006; Linehan, 1993). We add two more here. The key term in “internal working models” is “working.” Bowlby theorized that, to be maximally helpful, representational models of self and other need to change to reflect changing circumstances (Bowlby, 1973). However, in PDs, models of self and other do not change, but remain fixed and applied indiscriminately across situations. Informed in part by attachment theory’s emphasis on representational models, Young’s schema therapy extends cognitive behavioral therapy to address maladaptive models developed from adverse experiences in childhood, including a sense of the self as defective and others as untrustworthy (Young, 1994). Indeed, total scores on the Young Schema Questionnaire correlated highly with a corresponding total score for PD symptoms (Schmidt, Joiner, Young, & Telch, 1995). Furthermore, the mistrust/abuse schema was significantly associated with paranoid PD, whereas the insufficient self-control/self-discipline schema was significantly associated with borderline PD (Schmidt et al., 1995).
In addition to working with individuals who have PDs, it is helpful to work with their families (i.e., the context in which the PD developed). One example of an intervention using the biosocial model as a framework is the Family Connections program (Hoffman et al., 2005), which seeks to better inform family members of individuals with borderline PD about the symptoms their loved one is struggling with and how to help manage them using dialectical behavior therapy skills (Linehan, 1993). Interventions such as the Family Connections program can help family members intervene at the environmental level, potentially minimizing invalidation that would otherwise further escalate and perpetuate the symptoms of individuals with borderline PD.
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