An investigation of the mentalization-based model of borderline pathology in adolescents

Highlights

• Evaluation of a transgenerational mentalization-based theory of borderline personality disorder

• Impaired mental state reasoning may be transmitted from caregiver to offspring.

• Adolescent mentalizing mediates link between caregiver mentalizing and BPD features.

• Concrete mental state reasoning in caregivers is indirectly linked to adolescent BPD features.

Abstract

Objective

According to mentalization-based theory, transgenerational transmission of mentalization from caregiver to offspring is implicated in the pathogenesis of borderline personality disorder (BPD). Recent research has demonstrated an association between hypermentalizing (excessive, inaccurate mental state reasoning) and BPD, indicating the particular relevance of this form of mentalizing dysfunction to the transgenerational mentalization-based model. As yet, no study has empirically assessed a transgenerational mentalization-based model of BPD. The current study sought firstly to test the mentalization-based model, and additionally, to determine the form of mentalizing dysfunction in caregivers (e.g., hypo- or hypermentalizing) most relevant to a hypermentalizing model of BPD.

Method

Participants were a mixed sample of adolescents with BPD and a sample of non-clinical adolescents, and their respective primary caregivers (n = 102; 51 dyads). Using an ecologically valid measure of mentalization, mediational analyses were conducted to examine the relationships between caregiver mentalizing, adolescent mentalizing, and adolescent borderline features.

Results

Findings demonstrated that adolescent mentalization mediated the effect of caregiver mentalization on adolescent borderline personality pathology. Furthermore, results indicated that hypomentalizing in caregivers was related to adolescent borderline personality pathology via an effect on adolescent hypermentalizing.

Conclusions

Results provide empirical support for the mentalization-based model of BPD, and suggest the indirect influence of caregiver mentalization on adolescent borderline psychopathology. Results further indicate the relevance of caregiver hypomentalizing to a hypermentalizing model of BPD.

Introduction

Borderline personality disorder (BPD) is a psychiatric disorder associated with substantial functional impairment, including severe interpersonal dysfunction, affective instability, high rates of impulsive and self-damaging behaviors, and high suicide risk [1]. The public cost of BPD is likewise considerable, as patients utilize more treatment than those with other psychiatric disorders [2,3], attain fewer educational qualifications and experience higher rates of unemployment [4,5]. Converging evidence suggests that developmental precursors of BPD may be present as early as childhood [6], highlighting the importance of identifying early risk factors, and better defining developmental pathways [7].

Contemporary models of BPD identify environmental and social influences—such as quality of parental care, social learning and early attachment relationships—as mechanisms by which psychological vulnerability may be transmitted from caregiver to child [e.g., 8,9,10]. In line with this premise, mentalization, a key social cognitive process implicated in the development and maintenance of BPD psychopathology [11,12] is theorized to develop via a transgenerational pathway. Mentalization is the ability to infer and interpret the mental states (e.g., desires, beliefs, emotional states) of others and the self in relation to behaviors [13]. The mentalization-based model of psychopathology posits that a child's early social environment may hinder aspects of social and self development associated with certain psychopathology. Impairments of caregiver mentalizing may disrupt attachment processes and the child's emerging mentalizing capacity. Such maladaptive attachment processes, likely coupled with a biological or genetic predisposition, are theorized to enhance vulnerability for the emergence of BPD in later life. An impaired or compromised capacity for mentalization has been implicated in the development of BPD specifically, as well as several other psychiatric conditions [see 14 for a review].

The mentalization-based theory of BPD developed by Fonagy and colleagues [e.g., 11,12] identifies impaired mentalizing as antecedent to the interpersonal difficulties and affective and identity instability that are hallmark features of BPD. According to this theory, mentalization—also referred to as “reflective function” (RF) within attachment-related contexts [15,16]—can fundamentally be considered a social-cognitive process that develops within early attachment relationships. Accordingly, a primary caregiver's capacity to consider mental determinants of behavior and reflect on the subjective experiences of the child has been linked to secure attachment and to the child's socio-cognitive performance [17,18]. Disturbances of early attachment relationships, including experiences of trauma and maltreatment, as well as relatively more benign disturbances, such as insensitive and unempathic caregiving, can adversely impact a child's capacity to mentalize, with temporary failures in mentalizing occurring under conditions of arousal and interpersonal or attachment-related stress [19].

Mentalizing is posited to underpin several interrelated capacities integral to the developing self [15]. Emotion regulation and self-concept evolve primarily through the process of contingent and marked mirroring by the caregiver of infant affective states. By mirroring the infant's emotions, the caregiver displays emotions which are contingent upon the child's emotional experience and signals an awareness of the infant's mental states. Through this process, the infant develops second-order representations of emotions which then become internalized, thus fostering the beginnings of mental state awareness of the self [15]. Marked mirroring, which distinguishes the child's emotional experience from the caregiver's, via mannerisms such as exaggeration, allows the child to recognize the emotion as their own, distinct from the mother's emotional experience. These early foundations set the stage for mental state awareness that in turn promotes the development of affect regulation and a coherent self-concept [15,20]. By contrast, deficits in the development of mentalization processes may hamper affect regulatory capabilities and generate challenges to self-coherence [12,21], both of which are characteristic of BPD.

Empirical support for the relationship between mentalizing deficits and borderline pathology has been demonstrated in adults [see 22 for a review] and adolescents [23,24]. Moreover, investigations in adolescents with borderline pathology [23,24], and recently in adult BPD samples [25,26], indicate that compromised mentalizing in BPD may be characterized by an altered form of mentalizing termed hypermentalizing. Hypermentalizing is defined as over-interpretative reasoning regarding the mental states of others that goes beyond observable information, and may lead to misattributions of others' intentions. It is theorized to occur in contexts of high arousal [27].

Mentalizing in caregivers of individuals with BPD has, by contrast, received little empirical attention. However, impairments in caregiver mentalization may plausibly manifest in dysfunctional caregiving behaviors, and there is considerable evidence of poor parenting practices associated with BPD [28]. For instance, prospective research on this topic has shown that disrupted maternal communication in infancy, namely maternal withdrawal, was significantly correlated with the severity of BPD symptoms in young adulthood [29]. Moreover, retrospective reports of emotionally invalidating parenting practices are common among individuals with BPD, with caregivers described as overprotective, neglectful and indifferent [[30], [31], [32]]. Such behaviors are suggestive of a compromised mentalizing capacity on the part of the caregiver.

Recent research offers some support for the interrelationships between caregiver mentalizing, offspring mentalizing, and child psychopathology more generally. For instance, Ensink and colleagues [33] found that maternal mentalizing and child mentalizing were both related to child externalizing symptoms. Furthermore, studies with older children and adolescents have demonstrated links between mentalizing in caregivers and offspring, albeit primarily in non-clinical samples [34,35]. In caregiver-offspring dyads, mentalizing impairments have frequently been assessed on linear scales, on a continuum of high to low and operationalized as reflective functioning [e.g., 33,34,36]. In contrast, categories of mentalizing dysfunction (i.e., hypermentalizing, undermentalizing, and no mentalizing) have been measured using a computerized task [the Movie for the Assessment of Social Cognition; [37]. Assessment of caregiver mentalizing according to these categories of impairment may better elucidate the nature of relationships between caregiver and offspring mentalizing in the context of borderline pathology. Adolescent hypermentalizing, for instance, may be associated with specific caregiver mentalizing impairments, reflecting deficient or extremely impoverished mental state reasoning that is concrete and stimulus-driven (hypomentalizing) or alternatively, over-interpretive mental state reasoning (hypermentalizing) [38,39].

Adolescence may be an important developmental stage in which to study mentalization, in both adolescents and their caregivers, as it marks a period of risk for vulnerability and the presentation of psychopathology [40]. Accordingly, caregiver characteristics or behaviors may play an important role in potentiating or attenuating effects of underlying vulnerability during this period. Recent research has indicated problematic attachments to caregivers in samples of adolescents with BPD [41] and demonstrated the mediating role of adolescent mentalizing in the relationship between attachment coherence and borderline features in adolescence [42]. However, research has yet to examine a transgenerational theoretical account of mentalization in adolescent BPD using a dyadic design. Examination of a model linking caregiver mentalizing, adolescent mentalizing and borderline pathology may offer further insight into the complex socio-cognitive dynamics that occur for families of individuals with BPD during this period of development. Furthermore, it would provide an empirical assessment of the developmental mentalization-based model of BPD.

Therefore, the current study sought to assess the mentalization model of BPD. Furthermore, given mounting evidence for hypermentalizing profiles in those with BPD, mentalizing profiles in caregivers were also examined with adolescent hypermentalizing, as a mediating mechanism, within the model. In line with theory, it was firstly hypothesized that low caregiver mentalization would be associated with low levels of adolescent mentalization, which in turn would be associated with increases in severity of adolescent borderline psychopathology. Adolescent mentalization was further hypothesized to mediate the relationship between caregiver mentalization and adolescent borderline psychopathology. Finally, we aimed to examine the specific nature of mentalizing dysfunction in caregivers that may be most relevant to hypermentalizing and borderline pathology in adolescents. Given limited previous inquiry, this final aim was exploratory and focused on several subtypes of caregiver mentalizing.