Is BPD my personality

Familial transmission of borderline personality disorder

Summary

background

Research results consistently indicate that children of mothers with borderline personality disorder (BPD) have an increased risk of developing emotional and behavioral abnormalities and / or showing symptoms specific to BPD in adolescence.

Question

Which factors are involved in the familial transmission of BPD and which implications for practice can be derived from this?

Material and method

On the basis of a comprehensive literature search, current research findings on the familial transmission of BPD from mothers to their children were compiled and core findings were integrated in a transmission model.

Results

The transmission model postulated here depicts a complex interplay of various influencing factors and transmission mechanisms. In addition to factors on the part of the mother and child, external factors are integrated into the model. In addition, (epi-) genetic and prenatal influences, the importance of mother-child interaction and familial as well as social or societal influences are emphasized as transmission mechanisms. In addition, a potentially preventive effect of the help systems is assumed.

conclusion

Starting points are derived from the model that could help reduce vulnerability and stress factors and thus promote healthy child development in this risk group.

Abstract

Background

In recent years studies have shown consistent indications that maternal borderline personality disorder (BPD) puts children at risk for developing emotional and behavioral problems as well as for showing BPD-specific symptoms themselves in adolescence.

Objective

This article reviews factors contributing to the familial transmission of BPD and provides implications for practice derived from these findings.

Material and methods

Based on a comprehensive literature search current empirical findings on the familial transmission (mother to child) of BPD were aggregated and core findings were integrated into a transmission model.

Results

The transmission model postulated in this study shows a complex interplay of different influencing factors and mechanisms of transmission. In addition to mother- and child-related risk factors, external factors are integrated into the model. Furthermore, different mechanisms of transmission are emphasized: (epi) genetic and prenatal influences, the importance of mother-child interaction, familial and social resp. societal influences. A potential preventive effect of the welfare system is postulated.

Conclusion

Possible implications are derived from the model that could help to reduce vulnerability and stress factors and thus promote healthy development of children in this high-risk group.

In recent years, studies have increasingly analyzed the effects of maternal borderline personality disorder (BPD) on their children. An increased risk of psychological and psychosocial abnormalities is observed across various stages of development (Eyden et al. 2016; Florange and Herpertz 2019; Petfield et al. 2015). Based on these findings, a central task of research and practice is to gain a better understanding of this risk and subsequently reduce it.

Current aetiological models of BPD are based on a developmental psychopathological approach in which multifactorial conditions are taken into account. In addition to genetic and neural factors as well as stressful life events, the importance of the family and social environment as well as the thought and behavior patterns that develop over the course are emphasized (Stepp et al. 2016; Winsper 2018). In particular, the parent-child relationship is an important context for the development of BPD (Steele et al. 2019). This article aims to provide an overview of the current state of research on the familial transmission of BPD from parents to their children. The databases Web of Science, PubMed and PsychInfo searched for suitable studies. In addition to borderline personality disorder OR borderline OR BPD], parents [parent * OR mother OR father] and children [child * OR offspring OR infant * OR toddler], also familial transmission [familial transmission OR intergenerational transmission] were considered as search terms . In addition, the snowball method was used for relevant studies. On the basis of this comprehensive literature research, a transmission model was then derived, which is presented in the following section. In this context, reference is primarily made to the familial transmission of BPD from mothers to their children, as the literature search revealed that there is hardly any research on fathers with BPD. In addition to findings that indicate a transmission of BPS per se, there are particularly indications of the transmission of disorder (un) specific characteristics and vulnerabilities. At this point it should be mentioned that the focus of previous research has been on the identification of risk factors, while protective influences on the transmission of BPS have so far hardly been investigated. On the basis of the current findings and the transmission model presented here, implications are derived that can contribute to interrupting the cycle.

Familial transmission model

In the model of the intergenerational transmission of BPS shown here (Fig. 1), a distinction is made between 4 interacting factors. It is assumed that in addition to influencing factors on the part of the mother and child, external (family, social or societal) factors as well as measures through support systems also have an impact on the dyad. In addition, various potential transmission mechanisms of the BPS are postulated, whereby a complex interaction and interaction of the influencing factors and mechanisms is assumed.

Genetic transmission

There is clear evidence that the development of BPD symptoms in children of mothers with BPD is favored by genetic predispositions. In a twin study on BPS by Torgersen et al. (2012) genetic factors could explain 67% of the variance. However, estimates of the explanation of the variance in BPS by genetic factors vary between 42 and 70% (De Clercq et al. 2014). If only individual symptoms are considered, the heritability is higher. Especially for the characteristic of maternal impulsiveness, which is also a predictor of BPD symptoms in early adolescence (De Clercq et al. 2014), Beauchaine and Neuhaus (2008) found that 80% of the variance was explained by genetic factors.

Prenatal Influences

On the basis of retrospective case studies, there are frequent reports of early childhood abnormalities, premature birth and low Apgar scores in children of mothers with BPD (Blankley et al. 2015; Pare-Miron et al. 2016). The authors assume that these observations are attributed in particular to prenatal stress and low participation in prenatal care (Blankley et al. 2015) as well as to the consumption of alcohol, illegal drugs and tobacco during pregnancy (Pare-Miron et al. 2016) could become. However, it is unclear whether these maternal behaviors are actually causal factors for the early childhood abnormalities mentioned, and what effects are to be expected on the development of the children. In addition, it is not yet clear whether they are specific to mothers with BPD or also apply to mothers with other mental disorders.

Mother-child interaction

Various research projects consistently show evidence of abnormalities in mothers with BPD in parenting behavior and in interaction with their children (Eyden et al. 2016; Florange and Herpertz 2019; Petfield et al. 2015). In addition, various studies have looked at the effects of parenthood on mothers with BPD and their children. Although there is a lack of longitudinal studies, initial assumptions about the transmission of BPS can be derived from these studies.

Maternal parenting behavior.

Various studies indicate that mothers with BPD show a higher degree of anxious-disoriented behavior, which in turn is related to disorganized attachment (Hobson et al. 2005) and disinhibited behavior (Lyons-Ruth et al. 2019) on the part of the children. In addition, hostile behavior and low emotional availability of mothers with BPD seem to increase their children's risk, in particular, of developing internalizing and externalizing problem behavior and mental disorders (Kluczniok et al. 2018; Trupe et al. 2018). Frankel-Waldheter, et al. (2015) also report a connection between this maternal behavior and symptoms of BPD (affective instability and self-harm) in adolescence on the part of their children. Furthermore, consistently insensitive as well as intrusive behavior patterns are observed in mothers with BPD when interacting with their children (Apter et al. 2017; Crandell et al. 2003; Hobson et al. 2005). Zalewski et al. (2014) point to a parenting style in mothers with BPD that is characterized by the exercise of power, which manifests itself in the induction of feelings of guilt and in severe punishment (psychological control). This parenting style also seems to contribute to the transmission of BPD symptoms. Mahan et al. (2018) found a connection between psychological control of mothers and affective instability in adolescents. In addition, Reinelt et al. (2014) in their long-term study suggests that the observed change between an overprotective (controlling) and at the same time negative (hostile) style of upbringing plays a special role in the transmission of BPD symptoms from mother to child.

Maternal emotion regulation, mentalization and attribution.

Various findings suggest that maternal difficulties in regulating emotions influence mother-child interaction and maternal parenting behavior. In particular, the exercise of psychological control by inducing feelings of guilt and harsher punishment is predicted by the emotional dysregulation of mothers (Zalewski et al. 2014). This interaction could thus play a central role in the transmission of impaired emotion regulation and BPD symptoms. Kiel et al. (2011) emphasize the importance of a temporal interaction: The longer expressions of stress persisted on the part of the infants in their study, the greater the likelihood of insensitive behavior of the mothers with BPD, but not the mothers without BPD. With increasing maternal insensitivity, the stress of the children increased further. The relationship between the increased punishing or derogatory behavior of mothers with BPD when their children express anger is mediated in a further study by maternal difficulties in regulating emotions (Kiel et al. 2017). In children of mothers with BPD there are indications of dysfunctional self-regulation across various stages of development: In addition to abnormalities in emotional expressivity in the form of increased or no expression of fear when confronted with fear-inducing stimuli (Gratz et al. 2014; Whalen et al. 2015 ), atypical reactions to interpersonal stress, such as a dazed look or gaze averted from the mother, were observed in 2 or 3-month-old infants after a stress phase (Apter et al. 2017; Crandell et al. 2003). In addition, a connection between maternal BPD characteristics and stronger negative affects (frustration and fear) as well as less self-control (Zalewski et al. 2019) could be demonstrated in their children. Across all faults, it is increasingly assumed that emotional dysregulation plays a central role in the etiology and maintenance of mental disorders (Crowell et al. 2015; Fernandez et al. 2016) and can therefore also be seen as a central mechanism in the familial transmission of BPD (Carpenter and Trull 2013; Gratz et al. 2009 ).

Various studies indicate a reduced ability of mothers with BPD to correctly understand child sensitivities (mentalization) and subsequently to react appropriately to them (Marcoux et al. 2017; Schacht et al. 2013). In addition, negative attributions with regard to neutral expressions of emotions in their children (Elliot et al. 2014) and deficits in emotional communication skills were observed (Hobson et al. 2009), which makes it difficult to respond adequately to children's needs and possibly further promotes negative development processes (Elliot et al. 2009) al. 2014; Hobson et al. 2009). Anomalies on the part of the children that are related to the described maternal behavior relate in particular to problems in adopting an affective perspective and understanding the causes of emotions, as well as difficulties in labeling emotions (Schacht et al. 2013; Zalewski et al. 2019). So far, however, there are no studies that directly examine the influence of maternal mentalization and attributions on the development of BPD in their children.

The investigation of narrative representations in preschool children of mothers with BPD shows evidence of a pronounced fear of being abandoned, an incongruent and shame-laden self-image, role reversal and more negative expectations of the parent-child relationship than is observed in children of healthy mothers. These representations are interpreted as precursors of BPD-specific symptoms (Macfie et al. 2017, 2014; Macfie and Swan 2009). In line with this, a transmission of disorder-specific symptoms of BPD was observed in one of the few longitudinal studies (Barnow et al. 2013). In addition, a recently published prospective study provides initial evidence that emotional dysregulation and dissociation on the part of mothers with BPD have an influence on the development of dissociation in children (Lewis et al. 2020). The authors suspect that this connection is at least partially mediated by aspects of mother-child interaction, although findings at this point are still pending.

Experience of maternal stress.

In studies of self-perception, mothers with BPD state that they are less satisfied and feel more incompetent and more stressed in their motherhood than mothers without a mental disorder (Newman et al. 2007), whereby the experience of stress is the effect between the maternal BPD symptoms and the mental ones as well as psychosocial complaints on the part of the children (Dittrich et al. 2019). These findings emphasize the role of mothers' stressful experiences in the transmission of BPD.

Childish self-worth.

Furthermore, higher levels of maternal BPD symptoms are associated with a lower self-esteem in the children (Barnow et al. 2006; Herr et al. 2008), with the children also having an increased risk of mental health problems and more frequently reporting thoughts and plans for suicide (Barnow et al. 2006). In this context, too, mediation through mother-child interaction is at least partially conceivable.

Epigenetic Mechanisms

The evidence on gene-environment interaction is currently not clear. Sicorello and Schmahl (2019) highlight the DNA methylation of the oxytocin receptor gene as a possible epigenetic mechanism. Oxytocin is viewed in particular as a regulator of human social behavior, with individual differences within the oxytocin system inter alia. be associated with varying sensitivity to social signals, prosocial behavior, and stress reactivity in adults (Chen et al. 2011; Marsh et al. 2010; Puglia et al. 2015). Studies with healthy mothers found a connection between high oxytocin concentrations and sensitive maternal behavior as well as an intact mother-child bond (Feldman et al. 2013, 2012; Krol et al. 2019). In addition, the DNA methylation of the oxytocin receptor gene in infants can be predicted by the quality of maternal care behavior (Krol et al. 2019). Findings on BPD indicate lower oxytocin concentrations (Bertsch et al. 2013), whereby connections with experiences of abuse (Kluczniok et al. 2019) as well as disorganized attachment representations (Jobst et al. 2016) were found. Studies on the influence of maternal behavior on the oxytocin system of their children are still pending with regard to BPD.

External factors

Family context.

Another aspect that is important in the context of the transmission of BPS concerns the influence of the family context. An increased risk of neglect, abuse and mistreatment has been reported in children of mothers with BPD (Macfie and Kurdziel 2019). In particular, physical and emotional violence and neglect are associated with BPD symptoms in the young offspring (Kurdziel et al. 2018). The increased risk of child abuse is related both to their own experiences of abuse (Dittrich et al. 2018) and to difficulties in regulating emotions (Hiraoka et al. 2016) in mothers with BPD. However, it is also important to find that the reported experiences of violence among children and adolescents do not come exclusively from the mothers with BPD (Kurdziel et al.2018; Macfie and Kurdziel 2019). Furthermore, Feldman et al. (1995) found that children often witnessed a suicide attempt by their mother (24% of the children) or their father (19% of the children) with BPD. The family context is also often characterized by serious partnership conflicts and violence (Laporte et al. 2018; Whisman and Schonbrun 2009), postnatal drug abuse by mothers and partners, unstable family relationships (Laporte et al. 2018) and a high level of change in those living in the household People and a cohesion assessed as low (Feldman et al. 1995). In addition, many mothers with BPD are single parents (Barnow et al. 2006). These circumstances can represent risk factors for the development of the child, but there is a lack of systematic study results on the effects of these conditions on the transmission of BPD.

Social and societal context.

The social context of mothers with BPD, in particular the lack of professional prospects and financial problems, affects their experience of stress (Rosenbach and Renneberg 2019). In a study by Barnow et al. (2006) only half of the mothers with BPD have a job. In addition, two further studies show that BPD is often associated with social disadvantages, which are reflected in lower social support and integration (Lazarus and Cheavens 2017; Ramsauer et al. 2016). Not only mothers with BPD report that they feel much more isolated, building a stable social network can also be made more difficult for their children if they move more often and change schools (Feldman et al. 1995; Herr et al. 2008). At the age of 15, children of mothers with BPD rate their ability to form close friendships and be socially accepted less than adolescents of the same age of mothers without BPD (Herr et al. 2008). However, a more comprehensive understanding of the effects of the social and family context of mothers with BPD and their children on their development has so far been lacking.

Help systems

The influencing factor “help systems” includes in particular potentially protective measures of child and youth welfare as well as the health system, which can have a positive effect on mother, child and their interaction. While the effectiveness of disorder-specific therapies for BPD has already been extensively investigated and proven, to the best of our knowledge, their effects on the children of those affected - for example through a reduction in maternal symptoms - have not yet been investigated. It is assumed that improving the parenting skills of mothers with BPD on the one hand (e.g. through psychotherapy and disorder-specific parenting training) and on the other hand providing help with regard to family and social risk factors (e.g. B. through family and child / youth welfare systems) can exert a preventive influence. However, in order to be able to better assess the importance of this influencing factor with regard to counteracting the transmission of BPS, corresponding effectiveness studies are urgently required. Effects on the mother-child dyad through support for mothers with BPD from family assistance have not yet been adequately investigated. In addition, it is still unclear to what extent the hoped-for potential of the family and child / youth welfare systems will develop. Qualitative surveys (Bartsch et al. 2016; Renneberg et al. 2018) examined the perception of parents with BPD with regard to these help systems. In addition to a fear of stigmatization, they identified a distrust of the family and child / youth welfare systems on the part of the parents. Such negative perceptions are a hindrance in the sense that the parents develop inhibitions about seeking help.

Implications for Practice and Research

Based on the interaction of the influencing factors and mechanisms of the model postulated here, various starting points can be found that could help reduce vulnerability and stress factors and thus promote healthy child development in this risk group. Based on the postulated transmission model and experience from clinical practice, recommendations for working with mothers with BPD are derived below. In addition, implications for research are discussed.

The complex and extensive problems that BPS entails often makes it difficult to adequately consider the children in the treatment context. However, in line with a systemic view of the family, these should be given greater consideration in treatment in order to counteract unfavorable developmental processes at an early stage. The questions as to whether patients with BPD have children, where do they live and how they are doing are essential starting points (Renneberg et al. 2018). Based on the findings on prenatal influences, pregnancy in patients with BPD should also be addressed during treatment. If behavior is shown that poses a risk to the mother or child, the focus should be on informing the patient about potential consequences and on developing alternative behavior. It is important to be particularly sensitive to the fear of stigmatization and the distrust of the help systems (Renneberg et al. 2018).

Practical experience shows that mothers with BPD want to offer their children an environment that they mostly lacked in their own childhood. In addition, it is not uncommon for them to experience a feeling of belonging and an identity-forming effect in their motherhood role (Renneberg and Rosenbach 2016; Rosenbach et al. 2019). This is often associated with a large potential for change, which should be used in a targeted manner in cooperation with the available help system. For example, integrated parent-child therapies need to be expanded, both outpatient and (partially) inpatient, in order to cover the need for care (Renneberg et al. 2018). Lasting, reliable structures could reduce the hurdle for utilization. In order to facilitate access for those seeking help and specialists from the various disciplines and to support networking and closer cooperation, there should be a central, nationwide contact point (Bartsch et al. 2016; Renneberg et al. 2018). In order to improve the interdisciplinary practice of child and youth welfare as well as the health system and thus to optimize the help for children of affected mothers, the internet-based e-learning advanced training "Early help and early interventions in child protection" was developed. In a pilot study (Weber et al. 2012), in addition to building up knowledge, it was also possible to demonstrate better cooperation with other specialists. Possibly, these measures could also help to reduce the fears and reservations described by mothers with BPD about the support systems.

Based on the model, 3 concrete starting points for the treatment of mothers with BPD can be derived: (1) the development of maternal parenting skills to reduce dysfunctional parenting practices, (2) the reduction of the maternal stress experience and (3) an improvement of the maternal emotion regulation and its Ability to mentalize in dealing with your child. In this context, parental training courses that are specifically geared to the specifics of mothers with BPD could be very promising. Buck-Horstkotte et al. (2015) have developed a corresponding group training for mothers with BPD, which is evaluated in a current multicenter study (“ProChild”). A pilot study has already shown promising results (Renneberg and Rosenbach 2016). In addition, attachment-oriented intervention concepts with a focus on the mother-child relationship and the mother's ability to mentalize are useful starting points (for an overview: Erickson et al. 2019; Luyten et al. 2017).

A research area that has so far been underrepresented in the studies on the familial transmission of BPS concerns protective factors. Although there are extensive findings that emphasize the importance of protective factors and resilience factors (e.g. attachment, social competence, self-esteem) for a favorable socio-emotional development of children, their role in the transmission of mental illnesses has not been adequately investigated (Hosman et al. 2009). A case study by Paris et al. Provides initial indications of protective factors at the individual, family and social level that may reduce the risk of developing BPD. (2014). In interviews with adult sibling pairs, of which only one person met the criteria for BPS, the following protective factors were particularly highlighted: Emotion regulation strategies, future orientation, setting boundaries against people who abuse abuse, and supportive relationships. The latter is in line with observations from practice. These show that in addition to the mother, there are often other relevant caregivers in the child's environment. These often include people (e.g. relatives, educators, teachers) who have a positive effect on the child and who can expand existing internal representations on the part of the child through supportive relationship experiences. The result of a study by Berg-Nielsen and Wichström (2012) also suggests the influence of other relevant caregivers. The authors point out that the influence of a parental personality disorder on the children's behavior problems is reduced if the children live with both parents. It is obvious that the protective factors mentioned explain at least in part the favorable developmental trajectories observed in practice in children whose mothers have BPD. Strengthening these factors and the above-mentioned resilience factors that have been proven to promote development on the part of the children of mothers with BPD is a promising starting point.

conclusion for practice

  • Research findings suggest a complex interplay of various influencing factors and mechanisms in the intergenerational transmission of borderline personality disorder (BPD).

  • The postulated transmission mechanisms include mother-child interaction, familial and social / societal influences, genetic transmission, prenatal influences, epigenetic mechanisms as well as potentially preventive influences from child and youth welfare and the health system.

  • Scientific studies should focus more on protective and resilience factors for favorable developmental trajectories in children of mothers with BPD.

  • In the psychotherapeutic treatment of mothers with BPD, pregnancy and the presence of children should be given greater consideration.

  • Training and close collaboration of a multidisciplinary support network is important.

  • Training to build up parenting skills and improve maternal emotion regulation and the maternal ability to mentalize are promising starting points.

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