How Mothers "Spread" Borderline Personality Disorder to Children/ Show Me a Patient with BPD and I Will Show You a Patient Whose Mother Had BPD

Multigenerational Transmission of BPD from Mothers to their Children Since women in clinical settings with diagnosis of BPD comprise an estimated 75% of patient population, it is roughly estimated that over 6 million women in the United States are diagnosed with the disorder (Friedel, 2004). Stepp and others (2012) have recently begun to focus on mothers with BPD in order to better understand the impact of generationally transmitted components within the etiology of the disorder. Additionally, only sparse research has been undertaken and therefore few manualized efforts exist to guide the efforts of clinical professionals in developing targeted interventions for the high-risk population of children being raised by mothers with BPD (Skodol & Bender, 2003; Stepp et al., 2012). In the theoretical model, a child who is genetically vulnerable to the disorder and its related psychopathology is at increased risk from the invalidating experiences transacted within the child-parent relationship (Bandelow et al., 2005). This is especially true when the child is highly emotionally reactive (Krause, Mendelson, & Lynch, 2003). Conversely, children who have a lower level of emotionally reactivity may not have as difficult a time soliciting a positive response from caregivers, which in turn moderates their internalizing and externalizing symptoms with less emotional dysregulation (Bandelow et al., 2005). Thus, acceptance and warmth from caregivers can mitigate accumulative damage to children from neglect, abuse, and conflict otherwise present in the social environment (Stepp et al., 2012). Since nothing can be done to change the particular genetic vulnerabilities of children who are born to mothers with BPD, future researchers would be prudent to concentrate on the modification of parenting practices in order to intervene environmentally (Herr, Hammen, & Brennan, 2008). Hobson and colleagues (2009), researching the particular challenges of parents with BPD, find a dysfunctional display in the inter-relatedness of these patients with psychotherapists. The moment-to-moment interactions between patient and therapist may be compared to patients with dysthymia, due to intense and often heated exchanges coupled with idealizing and devaluing “flip-flopping” (Conroy et al., 2009). The ramifications of similar patterns of interacting carrying over into the patient’s exchanges with offspring may have far-reaching and negative, social-emotional consequences developmentally (Stepp et al., 2012). Unresolved trauma from the mother’s childhood tends to lead to a disorganized and unresolved attachment style that causes her parenting style to fluctuate unsteadily between hostile and passive (Paulson & Lejuez, 2006). Bio-social theorists (Linehan, 1993) are finding evidence that when the patient oscillates between hostile control and passive devaluation it has a deleterious effect on the infants’ ability to self regulate (Stepp et al., 2012). Furthermore, these mothers with BPD tend to model the very strategies their own parents used, thereby replicating the same invalidating environments for their children (Stepp et al., 2012). This is indicative of a generational “handing-down” of a dysfunctional parenting template that perpetuates the disorder trans-generationally (Stepp et al., 2012). Recent studies by Fonagy & Luyten (2012) and Schacht, Hammond, Marks, Wood, & Conroy (2012) have attempted to address epidemiological concerns about the heritability of BPD by examining comorbid features of maternal psychopathology and resultant psychosocial outcomes on their offspring. According to Stepp, Whalen, Pilkonios, Hipwell, & Levine (2012), the attentiveness of mothers with BPD was observed during free-play interactions with their infants, and compared with the results of the same interactions between healthy control mothers and their infants. The data collected suggested that infants of the mothers with BPD were less attentive and less interested in interacting with their mothers during the free play than were the infants of the healthy control mothers. One emerging theory from the research is that this dynamic leads to avoidant interaction patterns between mothers with BPD and their offspring. Further research suggests that gaze aversion, “dazed looks” (Hobson et al., 2005; Stepp et al., 2012), and less overall responsiveness occurs in infants whose mothers have BPD, compared with infants of mothers with no evidence of psychopathology (Johnson et al, 2006). Over time the infants of the mothers with psychiatric disorders showed increasing negative affect, more emotional dysregulation, and less satisfaction when reengaged with their mothers (Whalen, Dahl, & Silk, 2009). By the time these same infants were 12 months old, 80% of them (Hobson et al., 2005) had patterned behavior consistent with disorganized attachment style, as well as poor mood toward strangers (Stepp et al., 2012). Negative psychosocial consequential outcomes may include the children of mothers with BPD exhibiting poorer emotional regulation (Steinberg & Morris, 2001), increased fear of abandonment (Bandelow et al., 2005), and more negative parent-child relational expectations. These outcomes, in turn, may engender a shameful and incongruent sense of self, leading to disturbances in identity formation (Conroy et al., 2009; Newman et al., 2007). Children with a shameful and incongruent sense of self are more likely to engage in self injurious behavior and have dissociative symptoms, both of which are correlates of BPD (Hobson et al., 2005). Similarly, childhood internalizing and externalizing disorders have been shown to occur in patients with early deficits in their ability to self regulate (Eisenberg et al., 2001; Ogawa et al., 1997; Stepp et al., 2012; Suveg, Hoffman, Zeman, & Thomassin, 2009; Yates, 2004). Compared with children from healthy control mothers, school aged-adolescent children of mothers with BPD are at an increased risk of disruptive behavioral disorders and attention-deficit hyperactivity disorder (ADHD). These particular children are 6.8 times more likely than controls from healthy mothers to have depressive symptoms (Ghassabian, Herba, Roza, Govaert, Schenk, Jaddoe, & Tiemeier, 2012). Moreover, among this group are higher reported incidences of (Stepp et al., 2012) (1) cognitive and interpersonal vulnerability, (2) negative attributional style, (3) dysfunctional attitudinal behavior, (4) ruminative responsive style, (5) self-critical attitude, (6) insecure style of attachment, and (7) increased reassurance seeking behavior. Further, increased rates of psychiatric disorders are seen in children whose mothers have been diagnosed with BPD when compared with children of control mothers (Stepp et al., 2012). Global ratings of impairment are higher for the children from mothers with BPD. Even when adjusted for contributing factors such as childhood trauma, data found by Hobson and colleagues (2005) shows that maternal BPD continued to be a compelling factor correlating to poor outcomes in offspring. Within this same group of offspring of mothers with BPD, higher rates of anxiety, depression, and low self-esteem were observed than in children from healthy controls (Hobson et al., 2005). Finally, studying the effects of maternal BPD on 15-year old adolescents, Stepp and others (2012) observed lower social self-perception, increased fearful attachment styles, more chronic stress, and maternal hostility within the mother-adolescent dyad. Bandelow et al (2005) and Bornovalova et al (2006) theorize that parental criticism and invalidation of their children’s emotions causes the transmission and development of BPD. An invalidating home environment is associated with early-childhood social and emotional difficulties, as well as psychological distress later in adulthood (Bandelow et al., 2005; Bornovalova, et al., 2006). It may be that the mother invalidates the child due to her own inaccurate perception of her child’s emotional state. A BPD-afflicted mother who struggles to properly understand and manage her own feelings and emotions, and who herself has a history of parental invalidation from her early childhood, may lack the tools to model strategies for emotional socialization (Bandelow et al., 2005; Bornovalova, et al., 2006). Rather, such a mother would model ineffective ways of coping and managing stressful emotions, possibly even leading to neglect and abuse (Bandelow et al., 2005; Bornovalova, et al., 2006). When caregivers invalidate children’s emotional responses during early childhood, often the child learns to deny his own natural responses, disrupting the development of emotional regulatory and processing systems (Bandelow et al., 2005; Bornovalova, et al., 2006). Consequently, children of mothers with BPD -- who repeat the invalidating atmosphere of their own early childhoods -- grow up emotionally compromised systemically, and are likely to repeat the transgenerational pattern themselves (Bandelow et al., 2005; Bornovalova, et al., 2006). Treatment for children negatively impacted by maternal BPD may thwart the mechanisms of early-childhood transmission of the disorder, as well as the transgenerational repetition (Krause, et al., 2003; Stepp et al., 2012). The following are commonalities in parenting behaviors that typify mothers with Borderline Personality Disorder: (1) they use insensitive forms of communication; (2) are critical and intrusive; (3) use frightening comments and behavioral displays (Hobson et al., 2009); (3) demonstrate role confusion with offspring (Feldman et al., 1995); (4) inappropriately encourage offspring to adopt the parental role (Feldman et al., 1995); (5) put offspring in the role of “friend” or “confidant” (Feldman et al., 1995); (6) report high levels of distress as parents; (Macfie, Fitzpatrick, Rivas, & Cox, 2008); and (7) may turn abusive out of frustration and become despondent (Hobson et al., 2009; Stepp et al., 2012). The role-reversal becomes most apparent during the toddler period for children whose mothers have the disorder (Macfie, Fitzpatrick, Rivas, & Cox, 2008). Hobson et al (2009) theorize that the mother with BPD discourages the development of autonomy in her toddler in order to have her own needs met through an enmeshed closeness. Because such mothers fear abandonment, they are reluctant for the toddler to achieve independence (Stepp et al., 2012). Thus, the mother encourages the toddler to be more adult-like, grooming him in the role of confidant, peer, or even parent. In turn, this leads to disorganized attachment within the mother-child dyad (Stepp et al., 2012). Stepp et al (2012) compared psychiatrically healthy mother-child dyads with dyads of mothers with BPD and their infants, and found differences in parenting. For example, patients reported feeling less satisfied, less competent, and more distressed with their abilities to parent properly than the controls did (Stepp et al., 2012). Also, the mothers with BPD displayed less sensitivity and used fewer opportunities to structure their interactions with their infants than the controls demonstrated (Johnson et al., 2006). Eisenberg et al (1996) and Lunkenheimer, Shields & Cortina (2007) believe that the neglect and emotional under-involvement in the parent-child dyad displayed by caregivers with BPD may lead to feelings of emotional invalidation in their children, thereby increasing the risk to those children of developing BPD, themselves. Moreover, even after controlling for contributing factors such as infant irritability, Feldman et al (1995) found that personality disordered caregivers reserve less time for recommended infant care practices during at-home assessments. Further, data from research by Feldman and colleagues (1995) indicates that children aged 4 -18 are oftentimes exposed to frequent and sudden environmental instabilities such as maternal suicidal ideation, geographic changes to housing and school, and even removal by agencies from the family home (Feldman et al., 1995; Stepp et al., 2012). One complex issue researchers face when creating controlled trials to observe the parenting practices of mothers with BPD is that this group must be carefully disentangled from mothers with other forms of psychopathology instead of, or in addition to BPD (Bezirganian et al., 1993). In solving this issue, researchers selected mothers by the common discordant BPD parenting strategies characterized by “over-involved/intrusive” behaviors and “hostile control/coldness” (Whalen, Dahl, & Silk, 2009). In this way, researchers are able to use select criteria for mothers with BPD, versus mothers with BPD and confounding variables in which data becomes difficult to extrapolate and validate (Johnson et al., 2006; Stepp et al., 2012). When parents are psychiatrically healthy their “emotion related parenting practices” enable children to “emotionally socialize” through proper “emotional modeling” (Bezirganian et al., 1993). By contrast, mothers with a diagnosis of BPD are thought to administer a punishing disciplinary response when their children display strong emotions (Bezirganian et al., 1993). Also, these mothers use negative parenting behaviors that include the following: (1) criticizing (Eisenberg et al., 1996), (2) mocking (Eisenberg et al., 1996), and (3) punishing emotional expression of the child based on inaccurate perceptions about the child’s emotional state (Hobson et al., 2005; Stepp et al., 2012). Children may in turn extinguish, suppress, or conceal their emotions through “aggressive emotion regulation strategies” (Ogawa et al., 1997; Yates, 2004). Such children are left without the ability to effectively manage their own emotions through appropriate models of adaptive strategies (Steinberg & Morris, 2001). Further, they will likely emulate poor parenting strategies later in life with their own children (Stepp et al., 2012). Mothers with BPD are less likely to monitor or supervise their children (Clark, Kirisci, Mezzich, & Chung, 2008; Hoeve et al., 2007), which increases the likelihood of childhood injuries and delinquent behavior persisting into young adulthood (Petrass, Blitvich, & Finch, 2009). Moreover, these mothers frequently vacillate from harshly punishing their children to being overly permissive and failing to set limits or provide proper guidance (Hobson et al., 2005). Interventions aimed at teaching mothers with BPD to promote self-efficacy in their children by maintaining schedules and providing routines with structure have been shown to effectively decrease distress in their children (Lunkenheimer, Sheilds, & Cortina, 2007). Furthermore, mothers who learn to decrease their withdrawing and ignoring behaviors while developing a nurturing and stable environment for their offspring may decrease children’s risk of developing BPD or other psychiatric symptoms (Murphy, et al., 2009; Stepp et al., 2012).