Skip to main content
SpringerLink
Log in

Attachment and its Vicissitudes in Borderline Personality Disorder

  • Published:
Current Psychiatry Reports Aims and scope Submit manuscript

Abstract

This article reviews the recent literature on attachment and attachment-related constructs in borderline personality disorder, with attention given to how recent findings in this area may inform understanding of the mechanisms underlying the etiology, maintenance, and treatment of the disorder. Most findings on this topic have stemmed from three major areas of research, each of which is reviewed in this article: 1) developmental psychopathology studies; 2) experimental psychopathology studies, particularly those using a neuroscience approach; and 3) treatment studies that have examined variables relevant to attachment. Overall, these findings suggest that attachment and related constructs may factor greatly into the underlying psychopathology of borderline personality disorder and may significantly impact the process and outcome of psychotherapy for the disorder. These findings are discussed as they relate to existing theories and ongoing debates in the field, and the implications for future research and clinical practice are highlighted.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Blatt SJ, Auerbach JS, Levy KN. Mental representations in personality development, psychopathology, and the therapeutic process. Review of General Psychology. 1997;1(4):351–374.

    Article  Google Scholar 

  2. Fonagy P, Target M, Gergely G. Attachment and borderline personality disorder. A theory and some evidence. Psychiatric Clinics of North America. 2000;23(1):103–22, vii–viii.

    Google Scholar 

  3. Fonagy P, Leigh T, Steele M, Steele H, Kennedy R, Mattoon G, Target M, Gerber A. The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of Consulting and Clinical Psychology. 1996;64(1):22–31.

    Article  CAS  PubMed  Google Scholar 

  4. Gunderson JG. The borderline patient’s intolerance of aloneness: insecure attachments and therapist availability. American Journal of Psychiatry. 1996;153(6):752–8.

    CAS  PubMed  Google Scholar 

  5. Levy KN, Blatt SJ. Attachment theory and psychoanalysis: Further differentiation within insecure attachment patterns. Psychoanalytic Inquiry. 1999;19(4):541–575.

    Article  Google Scholar 

  6. Westen D, Lohr N, Silk KR, Gold L. Object relations and social cognition in borderlines, major depressives, and normals: A Thematic Apperception Test analysis. Psychological Assessment. 1990;2(4):355.

    Article  Google Scholar 

  7. Yeomans FE, & Levy, K. N. An object relations perspective on borderline personality. Acta Neuropsychiatrica. 2002;14:4.

    Article  Google Scholar 

  8. Bateman A, Fonagy P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. American Journal of Psychiatry. 2001;158(1):36–42.

    Article  CAS  PubMed  Google Scholar 

  9. Pilkonis P. Indentification of Risk Factors in Borderline Personality Disorder: The Example of Interpersonal Functioning. New Directions in Personality Disorder: Minneapolis Nationa Institute of Mental Health 2002.

  10. Gurvits IG, Koenigsberg HW, Siever LJ. Neurotransmitter dysfunction in patients with borderline personality disorder. Psychiatric Clinics of North America. 2000;23(1):27-40, vi.

    Article  CAS  PubMed  Google Scholar 

  11. Silk KR. Borderline personality disorder. Overview of biologic factors. Psychiatric Clinics of North America. 2000;23(1):61–75.

    Article  CAS  PubMed  Google Scholar 

  12. Levy KN, Clarkin JF, Yeomans FE, Scott LN, Wasserman RH, Kernberg OF. The mechanisms of change in the treatment of borderline personality disorder with Transference Focused Psychotherapy. Journal of Clinical Psychology. 2006;62(4):481–501.

    Article  PubMed  Google Scholar 

  13. Levy K. The Implications of Attachment Theory and Research for Understanding Borderline Personality Disorder. Development and Psychopathology. 2005;17:959–986.

    Article  PubMed  Google Scholar 

  14. Bowlby J. A secure base: Parent-child attachment and healthy human development. New York, NY, US: Basic Books, Inc; 1988.

  15. Blatt SJ, Levy KN. Attachment theory, psychoanalysis, personality development, and psychopathology. Psychoanalytic Inquiry. 2003;23(1):102–150.

    Article  Google Scholar 

  16. Diamond D, Clarkin J, Levine H, Levy K, Foelsch P, Yeomans F. Borderline conditions and attachment: A preliminary report. Psychoanalytic Inquiry. 1999;19(5):831–884.

    Article  Google Scholar 

  17. Farber BA, Lippert RA, Nevas DB. The therapist as attachment figure. Psychotherapy: Theory, Research, Practice, Training. 1995;32(2):204–212.

    Article  Google Scholar 

  18. Fonagy P, Gergely G, Jurist EL, Target M. Affect regulation, mentalization, and the development of the self. New York, NY, US: Other Press; 2002.

    Google Scholar 

  19. Holmes J. “Something there is that doesn’t love a wall”: John Bowlby, attachment theory, and psychoanalysis. In: Goldberg SM, Muir R, ed. Attachment theory: Social, developmental, and clinical perspectives. Hillsdale, NJ, England: Analytic Press, Inc; 1995:19–43.

    Google Scholar 

  20. Holmes J. Attachment, intimacy, autonomy: Using attachment theory in adult psychotherapy. Northvale, N.J.: J. Aronson; 1996.

    Google Scholar 

  21. Mackie AJ. Attachment theory: Its relevance to the therapeutic alliance. British Journal of Medical Psychology. 1981;54(3):203–212.

    CAS  PubMed  Google Scholar 

  22. Sable P. Attachment theory: Application to clinical practice with adults. Clinical Social Work Journal. 1992;20(3):271–283.

    Article  Google Scholar 

  23. Szajnberg NM, Crittenden PM. The transference refracted through the lens of attachment. Journal of the American Academy of Psychoanalysis. 1997;25(3):409–438.

    CAS  PubMed  Google Scholar 

  24. Barone L. Developmental protective and risk factors in borderline personality disorder: a study using the Adult Attachment Interview. Attachment and Human Development. 2003;5(1):64–77.

    Article  PubMed  Google Scholar 

  25. Dozier M. Attachment organization and treatment use for adults with serious psychopathological disorders. Development and Psychopathology. 1990;2(1):47–60.

    Article  Google Scholar 

  26. Tyrell C, Dozier M, Teague GB, Fallot RD. Effective treatment relationships for persons wtih serious pscyhiatric disorders: The importance of attachment states of mind. Journal of Consulting & Clinical Psychology. 1999;67:725–733.

    Article  Google Scholar 

  27. Dozier M, Cue KL, Barnett L. Clinicians as caregivers: Role of attachment organization in treatment. Journal of Consulting and Clinical Psychology. 1994;62(4):793–800.

    Article  CAS  PubMed  Google Scholar 

  28. Mallinckrodt B, Gantt DL, Coble HM. Attachment patterns in the psychotherapy relationship: Development of the Client Attachment to Therapist Scale. Journal of Counseling Psychology. 1995;42(3):307–317.

    Article  Google Scholar 

  29. Dozier M, Lomax L, Tyrell CL, Lee SW. The challenge of treatment for clients with dismissing states of mind. Attachment and Human Development. 2001;3(1):62–76.

    CAS  PubMed  Google Scholar 

  30. Levy K, N., Meehan KB, Kelly KM, Reynoso J, Clarkin JF, Kernberg OF. Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. Journal of Consulting & Clinical Psychology. 2006; 74(6):1027–1040

    Article  Google Scholar 

  31. •• Carlson EA, Egeland B, Sroufe LA. A prospective investigation of the development of borderline personality symptoms. Development and Psychopathology 2009; 21:1311–1334. The authors of this study used a prospective, longitudinal design to examine potential antecedents of BPD from infancy to adulthood. The findings suggest that temperament in addition to early relational factors in early childhood (e.g., attachment) are predictive of BPD symptoms in adulthood. Other disruptions in relationships, behavior, emotion, and self-representation in adolescence were also predictive of adult BPD, with self-representation acting as a mediator between early, disorganized attachment and adult BPD symptoms. These findings highlight the importance of early attachment and subsequent representations in the development of BPD, and add to our understanding of the trajectory of BPD symptomatology over time.

    Article  PubMed  Google Scholar 

  32. Crawford TN, Cohen PR, Chen H, et al. Early maternal separation and the trajectory of borderline personality disorder symptoms. Development and Psychopathology 2009;21:1013–1030.

    Article  PubMed  Google Scholar 

  33. Fonagy P, Luyten P. A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology 2009;21:1355–1381.

    Article  PubMed  Google Scholar 

  34. Kernberg OF. Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press; 1984.

    Google Scholar 

  35. Kobak R, Zajac K, Smith C. Adolescent attachment and trajectories of hostile-impulsive behavior: Implications for the development of personality disorders. Development and Psychopathology. 2009;21:839–851.

    Article  PubMed  Google Scholar 

  36. Patrick M, Hobson RP, Castle D, Howard R. Personality disorder and the mental representation of early social experience. Development and Psychopathology. 1994;6(2):375–388.

    Article  Google Scholar 

  37. Levy KN, Meehan KB, Weber M, Reynoso J, Clarkin JF. Attachment and borderline personality disorder: implications for psychotherapy. Psychopathology; 2005:64–74.

  38. Choi-Kain LW, Fitzmaurice GM, Zanarini MC, et al. The relationship between self-reported attachment styles, interpersonal dysfunction, and borderline personality disorder. Journal of Nervous and Mental Disease 2009;197:816–821.

    Article  PubMed  Google Scholar 

  39. Scott LN, Levy K, N., Pincus AL. Adult attachment, personality traits, and borderline personality disorder features in young adults. Journal of Personality Disorders. 2009;23(3):258–290.

    Article  PubMed  Google Scholar 

  40. Goodman M, Yehuda R. The relationship between psychological trauma and Borderline Personality Disorder. Psychiatric Annals. 2002;32(6):337.

    Google Scholar 

  41. Kaehler LA, Freyd JJ. Borderline personality characteristics: A betrayal trauma approach. Psychological Trauma: Theory, Research, Practice, and Policy 2009;1:216–268.

    Article  Google Scholar 

  42. Widom CS, Czaja SJ, Paris J. A prospective investigation of borderline personality disorder in abused and neglected children followed up into adulthood. Journal of Personality Disorders 2009;23:433–446.

    Article  PubMed  Google Scholar 

  43. Bierer LM, Yehuda R, Schmeidler J, Mitropoulou V, New AS, Silverman JM, Siever LJ. Abuse and neglect in childhood: relationship to personality disorder diagnoses. CNS Spectrums. 2003;8(10):737–754.

    PubMed  Google Scholar 

  44. Dutra L, Bureau J, Holmes B, et al. Quality of early care and childhood trauma: A prospective study of developmental pathways to dissociation. Journal of Nervous and Mental Disease 2009;197:383–390.

    Article  PubMed  Google Scholar 

  45. Selby EA, Braithwaite SR, Joiner TE, et al. Features of borderline personality disorder, perceived childhood emotional invalidation, and dysfunction within current romantic relationships. Journal of Family Psychology. 2009;22:885–893.

    Article  Google Scholar 

  46. Kochanska G, Philibert RA, Barry RA. Interplay of genes and early mother-child relationship in the development of self-regulation from toddler to preschool age. Journal of Child Psychology and Psychiatry 2009;50:1331–1338.

    Article  PubMed  Google Scholar 

  47. Zimmerman P, Mohr C, Spangler G. Genetic and attachment influences on adolescents’ regulation of autonomy and aggressiveness. Journal of Child Psychology and Psychiatry 2009;50:1339–1347.

    Article  Google Scholar 

  48. van IJzendoorn MH, Caspers K, Bakermans-Kranenburga MJ, Beach SRH, Philibert R. Methylation Matters: interaction between methylation density and serotonin transporter genotype predicts unresolved loss or trauma. Biol Psychiatry. 2010;68(5):405–407.

    Article  PubMed  Google Scholar 

  49. Hobson RP, Patrick MPH, Hobson JA, al. e. How mothers with borderline personality disorder relate to their year-old infants. British Journal of Psychiatry. 2009;195:325–330.

    Article  PubMed  Google Scholar 

  50. Macfie J, Swan SA. Representations of the caregiver-child relationship and of the self, and emotion regulation in the narratives of young children whose mothers have borderline personality disorder. Development and Psychopathology 2009;21:993–1011.

    Article  PubMed  Google Scholar 

  51. Herr NR, Hammen C, Brennan PA. Maternal borderline personality disorder symptoms and adolescent psychosocial functioning. Journal of Personality Disorders 2008;22:451–465.

    Article  PubMed  Google Scholar 

  52. Baumgartner T, Heinrichs M, Volanthen A, Fischbacher U, Fehr E. Oxytocin Shapes the Neural Circuitry of Trust and Trust Adaptations in Humans. Neuron. 2008;58:639–650.

    Article  CAS  PubMed  Google Scholar 

  53. •• King-Casas B, Sharp C, Lomax-Bream L, Lohrenz T, Fonagy P, Montague PR. The rupture and repair of cooperation in borderline personality disorder. Science. 2008;321(5890):806–810. This article seems to capture an aspect of the core disturbance that leads to painful and chaotic experiences in the lives of individuals experiencing BPD. Using an ecologically valid paradigm in which two individuals interact, it is clear that individuals with BPD face great difficulties in seeking harmony in interpersonal relationships. In addition, the study shines a light on the nature of difficulties individuals with BPD have in psychotherapy relationships—prone to lapses in collaboration, frequent ruptures, and potential difficulty with repair.

    Article  CAS  PubMed  Google Scholar 

  54. Ditzen B, Schaer M, Gabriel B, Bodenmann G, Ehlert U, Heinrichs M. Intranasal oxytocin increases positive communication and reduces cortisol levels during couple conflict. Biological Psychiatry. 2009;65:728–731.

    Article  CAS  PubMed  Google Scholar 

  55. Buchheim A, Heinrichs M, George C, Pokorny D, Koops E, Henningsen P, O’ Connor M-F, Gundel H. Oxytocin enhances the experience of attachment security. Psychoneuroendocrinology. 2009;34(9):1417–1422.

    Article  CAS  PubMed  Google Scholar 

  56. Domes G, Heinrichs M, Michel A, Berger C, Herpertz SC. Oxytocin improves “mind reading” in humans. Biological Psychiatry. 2007;61(6):731–733.

    Article  CAS  PubMed  Google Scholar 

  57. Fonagy P, Target M. Attachment and reflective function: their role in self-organization. Development and Psychopathology. 1997;9(4):679–700.

    Article  CAS  PubMed  Google Scholar 

  58. Theodoridou A, Rowe AC, Penton-Voak IS, Rogers PJ. Oxytocin and social perception: Oxytocin increases perceived facial trustworthiness and attractiveness. Hormones and Behavior. 2009;56:128–132.

    Article  CAS  PubMed  Google Scholar 

  59. Domes G, Czieschnek D, Weidler F, Berger C, Fast K, Herpertz SC. Recognition of facial affect in borderline personality disorder. Journal of Personality Disorders. 2008;22(2):135–147.

    Article  PubMed  Google Scholar 

  60. Simeon D, Bartz JA, Ketay S, Braun A, Hamilton H, Crystal S, Vicens V, Hollander E. Impact of oxytocin on stress-related dysphoria in borderline personality disorder (abstract). Biological Psychiatry. 2009;65(suppl 8):2445.

    Google Scholar 

  61. Bartz JA, Simeon D, Hamilton RK, Crystal S, Vicens V, Holander E. Effects of oxytocin in adults with borderline personality disorder and healthy controls (abstract). Biological Psychiatry. 2009;65(suppl 8):2445.

    Google Scholar 

  62. Stanley B, Siever LJ. The interpersonal dimension of borderline personality disorder: Toward a neuropeptide model. The American Journal of Psychiatry. 2010;167(1):24–39.

    Article  PubMed  Google Scholar 

  63. Posner MI, Rothbart MK. Developing mechanisms of self-regulation. Development and Psychopathology. 2000;12(3):427–441.

    Article  Google Scholar 

  64. Minzenberg MJ, Poole JH, Vinogradov S. A neurocognitive model of borderline personality disorder: Effects of childhood sexual abuse and relationship to adult social attachment disturbance. Development and Psychopathology. 2008;20:341–368.

    Article  PubMed  Google Scholar 

  65. • Koenigsberg HW, Siever LJ, Lee H, Pizzarello S, New AS, Goodman M, Cheng H, Flory J, Prohovnik I. Neural correlates of emotion processing in borderline personality disorder. Psychiatry Research. 2009;172:192–199. This is an important research report in that it signals the possibility that individuals with BPD may tend to use a fear circuit when confronted with emotional stimuli. This possibility should promote research that might bridge current foci of the nature of the disorder—emotion regulation dysfunction and mentalization deficit. Emotion regulation deficits may be the result of difficulty engaging in more reflective processes, particularly in emotional contexts.

    Article  PubMed  Google Scholar 

  66. Austin MA, Riniolo T, Porges SW. Borderline personality disorder and emotion regulation: Insights from the Polyvagal Theory. Brain and Cognition. 2007;65:69–76.

    Article  PubMed  Google Scholar 

  67. Levy KN, Meehan KB, Reynoso JS, Lenzenweger MF, Clarkin JF, Kernberg OF. The relation of reflective function to neurocognitive functioning in patients with borderline personality disorder. Journal of the American Psychoanalytic Association. 2005;53(4):1305–1309.

    Google Scholar 

  68. Levy KN, Clarkin JF, Kernberg OF. Change in attachment and reflective function in the treatment of borderline personality disorder with transference focused psychotherapy. Journal of Consulting and Clinical Psychology. 2006;74:481–501.

    Article  Google Scholar 

  69. Slade A. Attachment theory and research: Implications for theory and practice of individual psychotherapy. In: Cassidy J, Shaver P, eds. Handbook of Attachment Theory and Research. New York: Guilford Press; 1999.

    Google Scholar 

  70. Steele H, Steele M, Murphy A. Use of the Adult Attachment Interview to measure process and change in psychotherapy. Psychotherapy Research. 2009;19(6):633–643.

    Article  PubMed  Google Scholar 

  71. Levy KN, Kelly KM. Using interviews to assess adult attachment. In: Obegi JH, Berant E, eds. Attachment Theory and Research in Clinical Work with Adults. New York: Guilford; 2009:121–151.

    Google Scholar 

  72. Gunderson JG. Disturbed relationships as a phenotype for borderline personality disorder. American Journal of Psychiatry. 2007;164(11):1637–1640.

    Article  PubMed  Google Scholar 

  73. Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. American Journal of Psychiatry. 1999;156(10):1563–9.

    CAS  PubMed  Google Scholar 

  74. Bateman A, & Fonagy, P. Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder. American Journal of Psychiatry. 2009.

  75. Levy KN, Meehan KB, Kelly KM, Reynoso JS, Weber M, Clarkin JF, Kernberg OF. Change in Attachment Patterns and Reflective Function in a Randomized Control Trial of Transference-Focused Psychotherapy for Borderline Personality Disorder. Journal of Counseling & Clinical Psychology. 2006;74(6):1027–1040.

    Article  Google Scholar 

  76. McBride C, Atkinson L, Quilty LC, Bagby RM. Attachment as moderator of treatment outcome in major depression: A randomized control trial of interpersonal psychotherapy versus cognitive behavior therapy. Journal of Consulting and Clinical Psychology. 2006;74(6):1041–1054.

    Article  PubMed  Google Scholar 

  77. Clarkin JF, Levy, K. N., Lenzenweger, M. F, and Kernberg, O. F. Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study. American Journal of Psychiatry. 2007;164(6):922–928.

    Article  PubMed  Google Scholar 

  78. Doering S, Horz S, Rentrop M, Fischer-Kern M, Schuster P, Benecke C, Buchheim A, Martius P, Buchheim P. Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial. The British Journal of Psychiatry. 2010;196:389–395.

    Article  PubMed  Google Scholar 

  79. Kellogg S, Young J. Schema Therapy for Borderline Personality Disorder. Journal of Clinical Psychology. 2006;62:445–458.

    Article  PubMed  Google Scholar 

  80. Linehan MM, Schmidt HI, Dimeff LA, Craft JC, Kanter J, Comtois KA. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addictions. 1999;8(4):279–292.

    Article  CAS  PubMed  Google Scholar 

  81. Cortina M, Marrone M. Patient-therapist attachment: Impact on the therapeutic process and outcome. Attachment theory and the psychoanalytic process. London, England: Whurr Publishers, Ltd.; 2003:127.

    Google Scholar 

  82. Levy K, N., Edell WS, McGlashan TH. Depressive Experiences in Inpatients with Borderline Personality Disorder. Psychiatric Quarterly. 2007;78:129–143.

    Article  PubMed  Google Scholar 

  83. Fonagy P, Tallandini-Shallice M. On Some Problems of Psychoanalytic Research in Practice. Bulletin of the Anna Freud Centre. 1993;16:5–22.

    Google Scholar 

Download references

Acknowledgments

This work is supported in part by grants from the American Psychoanalytic Association (to Dr. Levy), International Psychoanalytic Association (to Dr. Levy), the National Institute of Mental Health (NIMH R36 grant no. 1R36MH086285 to Mr. Beeney), and the Dworman Foundation.

Disclosure

No potential conflicts of interest relevant to this article were reported.

Author information

Authors and Affiliations

  1. Department of Psychology, The Pennsylvania State University, 521 Moore Building, University Park, PA, 16802, USA

    Kenneth N. Levy, Joseph E. Beeney & Christina M. Temes

Authors
  1. Kenneth N. Levy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joseph E. Beeney
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christina M. Temes
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kenneth N. Levy.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Levy, K.N., Beeney, J.E. & Temes, C.M. Attachment and its Vicissitudes in Borderline Personality Disorder. Curr Psychiatry Rep 13, 50–59 (2011). https://doi.org/10.1007/s11920-010-0169-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11920-010-0169-8

Keywords

Search

Navigation