Download Borderline personality disorder and infants: interrupting

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
[email protected]
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
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 goodenough – child protection services
• “Early intervention” – in the perinatal period
either antenatal or postnatal – NOT in
adolescence!
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??
Why is it called BORDERLINE
personality disorder?
• Borderline between psychosis and neurosis
(Otto Kernberg, 1960s)
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…)
What is BPD (DSM IV & V)
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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
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
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
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
Research into BPD v PND
PubMed 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 (ie approx 1500/15)
• AND infant 34 (512/15)
• Perinatal borderline personality disorder 10
• Perinatal BPD AND infant 5
• Plenty in literature about trauma but that is not 1:1
equivalent to BPD
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
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 behavioural
organisation, interact less well w strangers
PROBLEMS CAUSED:
Child and young adult outcomes
• S. Stepp (2011): a large number of
internalising and externalising behaviours
• Winsper (2012): 11 yr olds: cognitive deficits,
parental conflict
• Lyons Ruth (2012, 2013): BPD
intergenerational transfer of problems
especially with maternal avoidance
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
Hindbrain
Basic life
function
Midbrain:
Emotions
Memory
Movement
Forebrain:
Thinking
Hindbrain
Basic life
function
Midbrain:
Emotions
Memory
Movement
Forebrain:
Thinking
INFANT
MOTHER
INFANT
MOTHER
INFANT
MOTHER
INFANT
MOTHER
INFANT
MOTHER
INFANT
MOTHER
INFANT
MOTHER
INFANT
MOTHER
INFANT
Adrenal
gland
MOTHER
INFANT
Adrenal
gland
MOTHER
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
INFANT
MOTHER
INFANT
MOTHER
INFANT
MOTHER
INFANT
Adrenal
gland
MOTHER
Infant
Mother
Grandmother
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 +
The overlap
BPD
EMTIONAL
DYSREGULATION
PND
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
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
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
Maternal Calming
Infant
Mother
Grandmother
Maternal Calming
AND ENHANCING MATERNAL
REFLECTIVE CAPACITY
Infant
Mother
Grandmother
Maternal Calming
AND ENHANCING MATERNAL
REFLECTIVE CAPACITY
Infant
Mother
Grandmother
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
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”
Troubled Parental Reflective
Functioning
• “that baby is having a temper tantrum to get
at me”
Can RF or PRF be taught?
• Yes, but only when the mother is in a calm
enough state of mind
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
eg Manipulative 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)
Validating
Acknowledging, 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)”
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, Marte Meo, 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
What happens when I tell a woman
she has BPD?
• 95% respond with relief, gratitude
• Things fall into place for them
Eg “I knew I had something different to the other women
with PND”
“I thought there was something wrong with me. Now I
know I am OK”
“I thought I was going crazy and now I know I am not”
“thank you! What can I do about it? What can I read
about it? What can I tell my family?”