Attachment studies, neuroscience, descriptive psychiatry and psychoanalysis
Donald C. Grant
The origin of the term Borderline as a psychiatric diagnosis and its evolution down to the current definition in DSM IV are discussed. Two features which keep recurring are, the unintegrated state of experiences of self and the tendency to action rather than thoughtfulness.
The psychoanalytic developmental view of personality and its disorders, including Borderline Personality Disorder, has received some confirmation from modern neuroscience and mother-infant attachment studies. Some of this evidence is reviewed.
Issues of treatment and management, are discussed. Freud defined thinking as understanding the relationships between things. This is the very thing the unintegrated Borderline patient cannot do and which we must try to do for him/her.
Finally, some outcome studies are presented.
BORDERS AND BORDERLINES
In a sense our present state of knowledge about Borderline states is a bit like being in a Borderline state ourselves. We have observations from mother-infant attachment studies, from neuroscience, from descriptive psychiatry and from psychoanalysis. We have all these bits but we dont quite know how to put them together to make a coherent whole. Living in this state of poorly connected ideas, even though it is only in our professional lives, might give us all a personal insight into what it is like to be in a Borderline state of mind, since not being able to put all of the separate bits of their experience together as a coherent life seems to be the very thing that Borderline patients cant do.
In this presentation, I want to talk about some of our ideas about Borderline patients, even though we cant synthesise them into a coherent whole at the present stage of our knowledge.
Some contributions from Descriptive Psychiatry
The term Borderline patient came into use in the 1930-40s to indicate patients who were not psychotic but were too disturbed to be classified as neurotic. It might be noted that the definition of neurosis had at that time become much narrower than it had been a few decades before and that if we look at Freuds published case histories his neurotic patients would today most probably be classified as DSM Axis II patients, mostly Borderline. Psychoanalysis and the psychotherapies derived from it then, have a long history of involvement in the treatment of Borderline states. At first the term Borderline was a diagnosis defined by what it wasnt ( i.e. neurosis or psychosis ) rather than what it was. In 1968 Grinker made an important attempt to define it by its positive features. He undertook a cluster analysis of the symptoms of 60 such patients. His results defined four sub-types of Borderline Personality Disorder.
TABLE 1. Grinkers four sub-types of Borderline patients.
Type 1 The Psychotic Border:
A. Inappropriate nonadaptive behaviour B. Problems with reality testing and sense of identity C. Negative behaviour and openly expressed anger
Type 2 Core Borderline Syndrome:
A. Pervasive negative affect B. Vacillating involvement with others C. Anger acted out D. Inconsistent self identity
Type 3: As if Group
A. Tendency to copy identity of others B. Affectless C. Behaviour more adaptive D. Relationships lacking in genuineness and spontaneity
Type 4. Neurotic Border
A. Anaclitic depression B. Anxiety C. Neurotic and narcissistic features
I want to draw your attention to a couple of features. First, poor Self identity is specified. 1B and 3A. Second, Action rather than containment is noted in 2C. Grinker also defined four key features common to all types. (slide 4)
Again poor Self identity is specified. 3
TABLE 2. Grinkers four core Borderline features.
Defective interpersonal relationships.
No consistent self identity.
Grinkers work showed that these patients formed a distinct entity, that he described as being stably unstable, and he refuted the previously held belief that these patients were pre-schizophrenic.
In 1975, seven years later, Gunderson and Singer continued this descriptive approach to defining Borderline Personality and defined 6 features, which were not so much different from Grinkers as an elaboration of them. They put more emphasis on impulsivity than Grinker had (slide5). Impulsivity, i.e. a tendency to action rather than thoughtfulness is specified in point 2.
TABLE 3. Gunderson and Singers six core Borderline features
Intense angry or depressed affect.
Superficial social adaption.
Transient psychotic episodes.
Loose thought associations.
The DSM IV description of Borderline Personality lists 9 features and again it is an elaboration of the work of Grinker and of Gunderson rather than any real departure from their descriptive approach. Impulsivity and poor self identity remain key features.
TABLE 4 DSM IV Borderline Personality Disorder
A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of overidealisation and devaluation.
Impulsiveness in at least two areas that are potentially self damaging. eg. spending, sex, substance use, shoplifting , reckless driving, binge eating.
Affective instability: marked shifts from baseline mood to depression, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days.
Inappropriate intense anger or lack of control of anger. eg. frequent displays of temper, constant anger, recurrent physical fights.
Recurrent suicidal threats, gestures or behaviour, or self mutilating behaviour.
Marked and persistent identity disturbance manifested by uncertainty about at least two of the following: self image, sexual orientation, long term goals or career choice, type of friends desired, preferred values.
Chronic feelings of emptiness or boredom.
Frantic efforts to avoid real of imagined abandonment.
Transient psychotic episodes.
The descriptive approach adopted by these studies does not incorporate the developmental perspective that psychoanalysis brings. However, two recent lines of empirical research do and are in addition beginning to provide confirmatory evidence of the poorly integrated sense of self and tendency to act rather than think, illustrated by the descriptive studies and emphasized in psychoanalysis by concepts such as splitting and projective identification. These two recent lines of research are Mother/Infant Attachment studies and Neuroscience.
**Some contributions from Attachment studies **
It is beyond the scope of this presentation to go into the large body of research that Attachment studies have produced, so I shall just summarise some of the results that are relevant to this discussion of Borderline States.
| ----- | |
iNFANT ATTACHMENT TYPE-(ASS)
CAREGIVER DSM DIAGNOSIS
| | |
SECURE AUTONOMOUS (F)
Away from caregiver
UNRESOLVED DISORGANISED U/d
I want to bring your attention to correlations between the infant attachment type, revealed in the Ainsworth Strange Situation(ASS), second column from the left in table 5, and the caregiver attachment type, revealed by the Adult Attachment Interview (AAI), second column from the right in table 5. One might argue that these correlations are genetic, but it has been found that one infant may have different attachment types to different caregivers. This makes it unlikely there is a simple genetic explanation for the observed correlation between infant attachment type and the caregivers Adult Attachment type (Main 2000). These observations from outside of the psychoanalytic setting, provide empirical evidence for the importance of environmental and experiential factors in the developing organization of both the normal and the pathological mind confirming what psychoanalytic observation suggests.
Furthermore, the attachment type of the caregiver correlates with the DSM axis II diagnosis in that care-giver. Patients with a DSM diagnosis of Borderline Personality Disorder were found by Fonagy (2000) to show predominately the preoccupied attachment type on the AAI. Preoccupied attachment adults in turn, correlate with resistant/ambivalent infant attachment in the ASS. Whether resistant/ambivalent infants in their turn complete the circle and develop into adults with Borderline Personality Disorder has yet to be investigated.
These observations do not constitute a coherent theory of personality development or its pathology in Borderline States. I mention them to illustrate that some consistent correlations between DSM axis 2 diagnosis, Adult Attachment type and infant attachment type have been demonstrated. Our present capacity to conceptualise the nature of these relationships and understand their meaning is still rudimentary. The promise of these studies is that they might add an empirical dimension to complement psychoanalytic studies of early infant development.
Some contributions from Neuroscience
The second line of research which in the last decade has seemed to promise much to aid our understanding of DSM axis II pathology is neuroscience. Over the last decade neuroscience has begun to throw light on the biology of the mind. I am talking now about subjective mental experiences,--emotions, thoughts, memories etc. I am not talking about the biology of behaviour as in simple conditioned reflexes.
Freuds first theory of the mind was a biological one. He did not publish it in his lifetime as it was too speculative. He did however detail it in a series of letters to Wilhelm Fliess, his friend in Berlin. In the late 1890s Freud asked Fliess to destroy the letters as he was destroying all of his own notes. He had decided that the knowledge of neuroscience at that time was insufficient to construct a biology of the mind and said that henceforth he (Freud) would have to conduct his clinical studies as if the brain did not exist and formulate his hypotheses in purely psychological terms.
Fliess however did not destroy the letters. They turned up after the first world war in the hands of a Paris second hand bookseller. Fliesss widow, desperate for money, was offering them for sale. Freud was informed. He asked Marie Buonaparte, a French analyst, to buy them and destroy them. She bought them but refused to destroy them and eventually donated them to the Freud Archives in London. That is how we know about Freuds first attempt to formulate a biology of the mind. It has now been published as The Project for a Scientific Psychology in volume 1 of the Standard Edition of Freuds complete works.
Again, it is beyond the scope of this presentation to diverge into all of the details of The Project but some of them are quite interesting. For example, Freud argued that for the human mind to work the way it does it was necessary to postulate the existence of what he called contact barriers between neurons. These were points on the axons at which the passage of an impulse from one cell body to another could be either blocked to permitted to pass. Of course, we now know these points as synapses. At the time Freud was writing however, it was widely held that neurons were in direct unbroken contact with each other as a syncytium.
Although Freud chose around 1895 to proceed as if there were no associated biology of mental processes he never wavered from the view that there was one. It was just that we didnt know enough to say anything sensible about it. In the last decade this has at last begun to change. The life cycle of neurons is better understood with its genetic and environmental influences. Imaging of brain function as well as structure is now possible enabling us to see which parts of the brain are active in association with various mental states.
Most of us were taught that the structure of the central nervous system (CNS) is genetically determined and that once the structure has been put in place following the blueprint, it is static and that even after injury no regeneration occurs, although functions can be taken over to a limited extent by other parts. We now know this is not anything like the full picture. Brain structure, at least in certain areas, is much more dynamic and changes in it are much more experience driven than we used to think. The following research studies show some of the dynamic processes that we now know take place in the CNS throughout life. I am making no attempt to formulate an integrated biology of the mind which would be far too ambitious. However, neuroscience has provided strong evidence that we need to adopt an experience-driven developmental perspective to understand the structure and functioning of the brain, and therefore the mind.
The human genome.
The results of the Human Genome Project published in 2001 (Nature 2001) contained a few surprises. One was that the total number of genes in the human genome is only about 30,000 not the 100,000 that most expected. For comparison, the genome of the nematode worm contains 18,000 genes. The related surprise was that the number of genes in common with other animals is quite high. In the case of the RIKEN mouse it is 81%. These observations are not consistent with the popular idea that there is a gene for every human characteristic and that the difference between humans and other animals is to be found in their genes. The authors of the report in Nature suggested that the difference lies in the way that protein synthesis is controlled. They suggested that the same genes can interact in different ways and combinations to form different proteins. Given that the difference between humans and other animals lies in the greater complexity of our brains rather than in our bodies that are basically the same design as say the Great Apes what then determines protein synthesis in our brains? Kandel (1998) showed that both genetically encoded information and neural activation itself i.e. experiences of the self interacting with objects, can result in the activation of genes that lead to the creation of the biologically active proteins that shape the detailed architecture of the brain. He was awarded the Nobel Prize in 2000 for his work.
Examples of experience driven brain architecture.
The Visual Cortex
My first example is a relatively simple one from the neuroscience of perception.
Wiesel T 1982 and Hubel D 1988, who were awarded the Nobel Prize in 1981, conducted an extensive and influential series of experiments on the development of the visual cortex of the cat. They showed that the organisation of the adult visual cortex relies heavily on early visual experiences.
**The Hippocampus **
The functions of the hippocampus are more subtle than the visual cortex, having to do with memory and emotion but similar observations have been made. Kemperman G et al (1997) showed that there were observable anatomical changes in the hippocampi of rodents raised in enriched environments when compared to those raised in low stimulus environments. There was an increase in both the volume and the number of neurons in the hippocampi of the rodents raised in the enriched environment.
Magnetic Resonance Imaging (MRI) has demonstrated an association between early maltreatment and reduction in the size of the left hippocampus in humans. Studies have shown detectable reductions in size in the left hippocampus of Vietnam veterans (Bremner et al 1995) and of adults with post traumatic stress disorder, who had a history of physical or sexual abuse in childhood (Bremmer et al 1997quoted in Scientific American March 2002 ). This has been confirmed in another study of women who were sexually abused as children (Stein et al 1997). Bremner suggests that the hippocampus normally functions to integrate the memory of different aspects of experience (time, place, context, emotional state of self and other, separate modalities of perception i.e. visual, auditory, olfactory, tactile etc.) into a coherent whole. The memories of these different elements of experience are stored in different places in the brain and the hippocampus has the function of reconstructing a coherent memory from these separate elements. This integration of self experiences and/or their memory is one of the things which clinical work teaches us that Borderline patients cannot do at all well, suggesting pathological hippocampal development and functioning in these patients.
The Corticotropin Releasing Factor (CRF) System.
The corticotropin releasing factor (CRF) system controls reactions to stress. We now know this system is much more extensive than previously thought. It is not just a system that connects the hypothalamus to the anterior pituitary via the hypothalamic-pituitary portal circulation. There are corticotropin releasing factor neurons from the cortex to the brain stem all controlling and modulating stress responses. Rodent studies have shown that early maternal separation causes an increase in corticotropin releasing factor sensitive neurons throughout the CNS and hyperactivity of the stress response (Ladd et al 1996). Women who have suffered sexual abuse in childhood have also been shown to have a persistent hypersensitivity of their stress response (Ladd et al 2000 )
The Nor-adrenergic System.
There is evidence that the detailed architecture of the noradrenergic system too is experientially driven. Yohimbine , an alpha 2 adrenergic receptor antagonist produces behavioural disturbances similar to anxiety reactions in adult monkeys with a history of early life trauma but not those without such a history (Rosenblum 1984). This suggests permanent or at least long-standing change in the CNS noradrenergic system in traumatised primates.
The brains functional asymmetry, and its consequent need for integrative mechanisms to unify experience, has emerged as an important issue if we are to understand states of failed integration such as Borderline states. We have known for a long time that the human brain is functionally asymmetrical although the macroscopic anatomy of the two sides is very similar. For example, it is old knowledge that the language centres are in the left hemisphere. The new ability to image brain functioning has demonstrated that the functional asymmetry is even more extensive than we knew. (Seigal 2001) The right hemisphere primarily regulates bodily processes, affective experiences and the perception of affect in others. The left hemisphere has a primary linguistic processing function and processes information in a linear logic paradigm, looking for cause-effect relationships. There is not an absolute separation of these functions, but each cerebral hemisphere has its own dominant function.
Using the investigatory techique of EEG coherence which measures the level of development of integrated brain functioning, Martin H Teicher (1997 quoted in Scientific American March 2002) studied a group of 15 psychiatric patients with a confirmed history of intense physical or sexual abuse in childhood, compared with controls. He found the right cerebral hemispheres of both groups to be equally developed. However the integrated functioning of the left hemisphere of the abused group was significantly underdeveloped. This experimental observation suggests that abused individuals are going to have a deficit in logical thinking, which is more associated with the left hemisphere, rather than a deficit in the ability to feel emotion, which is more associated with the right hemisphere, and indeed we see this in Borderline patients who often seen to be too emotional and impulsive, and not thoughtful enough. Teicher (1997 quoted in Scientific American March 2002)) also showed that the middle section of the corpus callosum which is the main channel of communication between the two hemispheres, was reduced in size in adults who had been abused as children, emotional neglect having the greatest effect in boys and sexual abuse in girls. This again points to deficient integration of brain and therefore mind functioning in victims of childhood abuse which is a frequent feature of the histories of Borderline patients.
This new, more dynamic understanding of brain development and functioning links to the issues of Attachment Theory much better than the old static brain view did. If this line of thought is correct then a childs carer who is unable to offer secure attachment experiences, inadvertently facilitates the encoding of inadequate neurological structures in the infants brain. An infants avoidant, ambivalent or disorganised attachments might be expected to give rise to abnormal brain development that is reflected in the mind, most probably resulting in what we classify as Personality Disorders. Of course this is an oversimplified picture and there is still much to learn. However these studies are exciting as they seem to point to a new biological paradigm of a brain whose structure and functioning is not just genetically driven and static. It is experience driven within broad genetically determined limits and is in dynamic interaction with the environment throughout life but particularly in infancy. This new paradigm of neuroscience is more in harmony with the developmental paradigm of psychoanalysis i.e. of a brain/mind that is developmental, experience driven within broad genetically determined limits and has a dynamic relation to the environment particularly in early life. This offers a real opportunity for the two fields to become complementary fields of study as Freud hoped they eventually would and for each to enrich the other in the struggle to understand both normal and pathological development of the human brain/mind. In his recent paper, Biology and the future of psychoanalysis: a new intellectual framework for psychiatry revisited Eric Kandel discusses 8 areas in which he believes neuroscience and psychoanalysis could join together and make important contributions to each other and to the research effort to understand the brain/mind. They are,
1 The nature of unconscious processes.
2 The nature of psychological causality.
3 Psychological causality and psychotherapy.
4 Early experience and the predisposition to mental illness.
5 The preconscious, the unconscious and the prefrontal cortex.
6 Sexual orientation.
7 Psychotherapy and structural changes in the brain.
8 Psychopharmacology as an adjunct to psychoanalysis.
Even though our understanding of the causes and essential nature of Borderline Personality is rudimentary the task of managing these patients still usually falls to us as clinicians. This is the nature of clinical practice. Every day clinicians of all types are called upon to make clinical decisions on the basis of incomplete or conflicting scientific evidence. To my mind that is why clinical practice involving working with individual patients is a skill that must be learned in practice from long experience with different types of patient and cant be adequately undertaken by just following guidelines based on inadequate science which is not yet able to answer the questions patients confront us with on a daily basis.
However science can help us and what we can extract as two consistent themes, from the descriptive, attachment and neuroscience studies I have outlined, is that Axis II pathology, particularly cluster B with its major category of Borderline Personality Disorder involves unintegrated self experiences along with a tendency to impulsivity i.e. a tendency to act without detouring an emotionally driven impulse through thinking first (most probably detouring through the left hemisphere). As a result of these twin deficits in self experience and thinking, emotional experiences cannot be identified and thought about as events in an integrated life belonging to oneself. Instead the source of both good and bad experiences is felt to be outside of oneself. Every good experience is attributed to the presence of a good object who must then be possessed, and every bad experience is attributed to the presence of a bad object who must then be attacked and got rid of. This projection of fragments of self experiences into others and their subsequent identification as attributes of the other, who must then be dealt with, is a primitive mental mechanism that replaces the ability to think about ones own internal emotional experiences. It is, of course, what Melanie Klein described as projective identification, to distinguish it from the more simple process of the projection of an idea.
Some who dont actually treat patients, dismiss this formulation as an arcane and esoteric hypothesis, but those who actually work with Borderline patients will know that they do this all the time, since you will have felt yourself on the receiving end of it often enough---sometimes flattered as the impossibly good object and at other times attacked as the impossibly bad object. Sooner or later Borderline patients in hospital, will be found splitting staff into good and bad groups. The bad staff group who can do no good at all, are subject to unremitting hostility. The good staff group who can do no wrong, are seduced with flattery. The greatest danger we all face in this situation is to mistake this primitive mental functioning of the patient for reality. If you have been designated the good object it is always tempting to delude yourself that you really are more sensitive, more caring, more devoted to your patients and more giving than those who have been designated the bad object. It might even be true that you are a little bit but not to the extent that the patient believes. If you have been designated the bad object you find yourself subject to the most unfair and outrageous criticisms and attacks from the Borderline patient. In either case strong reactions are aroused in us.
This brings me to the issue of countertransference which Paula Heiman (IPA Congress 1949) clarified. The patient operating with the primitive defense of projective identification relates to his others as if they really were what he has projected on to them. If you have become a Borderline patients good object you will not only feel praised and appreciated but also a subtle pressure to show you are worthy of all this praise and appreciation by keeping up your efforts and struggling harder to do even better. This process can spiral to disaster. The seduction by praise may progress to take on a physical then sexual dimension. Freud (1915) warned us as far back as 1915 not to make the mistake of believing that the patients declaration of love has anything to do with the reality of who you are, tempting though that may be. From the earliest stage when you first experience your ego being massaged you need to be able to recognise your own pleasure as countertransference being evoked by the patient enacting unintegrated mental states, not as acknowledgment of your perfection in reality. Similarly, if you are designated the bad object and find yourself feeling resentful and angry at being unfairly criticised and unappreciated by the Borderline patient despite all of your best efforts, it is vital that this too be recognised and thought about as countertransference in the context of the Borderline psychodynamics, and not reacted to behaviourally in the real world. It is our job to convert these countertransference emotions into thinking about the patients mental state rather than reacting to them i.e. it is our job to use our left hemispheres as a sort of proxy for our patients who havnt developed a sufficiently functional one themselves. If we can do this and process our reactions through thought before we act on them, we have already taken an important step in the treatment and management of Borderline patients.
It may sound simple enough but never underestimate the difficulty of this task. Always remember the power of this primitive mental functioning to evoke reactions rather than thinking in the staff who are subjected to it. As well as the patients needs the staffs capacity to contain the powerful countertransference emotions being evoked by the Borderline patient must receive continual attention and evaluation. By contain, I mean the ability to be conscious of the emotions being evoked by the patient in you, to refrain from reacting to them, and instead to represent them in language so that you can think about what they mean and then and only then to act, professionally and appropriately. We also have to be honest enough to admit that we all have a limit to our capacity for this sort of containing work and this too must be taken into consideration so that you and other staff are not asked to bear more than you can.
This containment of the Borderline psychodynamics in the patient/staff interaction is a major factor in halting the downward spiral of patient action, leading to staff re-action, leading to patient re-action etc. This reduction in mutual acting-out alone is a worthwhile goal with these patients. With some there is a further bonus in that the level of acting-out may be reduced to a point where individual psychotherapy becomes possible. With some at least further gains can then be made over the long term. ** **
Finally I want to briefly discuss some outcome studies. Although you may sometimes hear non-analytic clinicians, who are not familiar with the relevant literature, say that there is no evidence that psychoanalysis works the fact is that psychoanalysis is the most intensively researched and studied treatment in all of psychiatry. The problem for psychoanalysis and its derivative therapies is not that there is no outcome research or that it is negative. The problem is that the huge body of published research is ignored and we still hear people say that psychoanalysis and psychoanalytic psychotherapy are treatments of unproven effectiveness.
The research consists of a large body of empirical research in addition to the thousands of published case studies. Norman Doidge (1997) published an excellent overview of empirical evidence for the efficacy of psychoanalysis and psychoanalytic psychotherapy in Psychoanalytic Inquiry in 1997. Ill mention a sample of studies from his review.
Stevenson and Meares in NSW studied patients with Borderline Personality Disorder. The most frequently observed changes were reductions in impulsivity, affect instability, anger and suicidal behaviour. 70% met criteria for Borderline Personality at 2 year follow-up compared with 100% at intake.
The Menninger Psychotherapy Studies.
Kernbergs 15 year follow-up showed that Borderline patients did better with a psychoanalytically orientated technique paying meticulous attention to transference issues in conjuction with limit setting.
Wallersteins 30 year follow-up of the same patients showed that the psychoanalytically treated group and the more supportively treated group tended to converge after 30 years. But 30 years is half a lifetime and if the psychoanaytic group functioned significantly better for much of that 30 years, as Kernbergs study showed they did, then it is still the preferred treatment...
Bannon Perry and Innani studied patients with Personality Disorders including Borderlines who received once a week to five times a week psychoanalytic treatment. They found that patients with therapy remit 3-4 times faster than those without. Patients in once a week treatment took 2.45 years for a 50% remission rate. Patients in twice a week treatment took only 1.22 years for a 50% remission rate.
This is only a tiny sample of the studies reviewed by Doidge. His paper is forty eight pages long and includes five pages of references.
While not claiming to have the cure for Borderline Personality Disorder psychoanalytically informed long-term therapy has been shown to achieve positive results, and until recently no other form of therapy had been shown, by empirical evidence, to be of value in the treatment of Borderline patients.
The one exception now, is Marcia Linehans study of the treatment of Borderline patients using Dialectical Behaviour Therapy (DBT). Yet even in this research she applied some principles which are more associated with Psychoanalysis than with Cognitive Behaviour Therapy. The main one being the need for the therapist to constantly monitor his/her countertransference to ensure that his/her behaviour is not driven by it. During the one year of treatment her patients improved in two out of the six dimensions that were measured. Not unexpectedly perhaps, these were the two behavioural dimensions viz. episodes of parasuicide and days in hospital. The measures of depression, hopelessness, suicidal ideation and reasons for going on living, were at no stage improved compared to the control group.(1991) After cessation of treatment the results were not as good as hoped. During the first six months after DBT the patients continued to have less incidents of parasuicide but had as many days in hospital as the controls. During the second six months following DBT this reversed and the DBT group had as many parasuicide episodes as the control group but less days in hospital (1993).
I am not trying to get into a fruitless debate about whether Psychoanalysis or DBT is better for these patients. Both approaches have some demonstrable value. While we still have many more questions than answers about the origin and the treatment of Borderline states, there is sufficient evidence to say that if these patients are managed by professionals, who take steps to remain thoughtful and rational themselves in the face of the chaos and disorder these patients create in their lives and their therapy , then many can be expected to improve.
Anderson S W, Bechara A, Damasio H, Tranel D, Damasio A R (1999) Impairment of social and moral behaviour related to early damage in human prefrontal cortex. Nature Neuroscience 2(11):1032-1037
Benes F (1998) Human brain growth spans decades. Amer. J. Psychiatry 155:1489
Bremner J, Randall P, Scott M, Bronen R (1995) MRI-based measurement of hippocampal volume in patients with combat-related post-traumatic stress disorder. Amer. J. Psych 152:973-981
Chechik G., Meilijson I., Ruppin E., (1999) Neuronal regulation: a mechanism for synaptic pruning during brain maturation. Neural Computation 11, 2061-2080
Chiron C (1997) The right brain is dominant in human infants. Brain 120:1057-1096
Doidge.N (1997) Empirical evidence for the efficacy of psychoanalytic therapies and psychoanalysis: an overview. Psychoanalytic Inquiry. Supplement. Extended dynamic psychotherapy pgs 102-150.
Doidge N, Simon B, Brauer L, Grant D, First M, Brunshaw A. Lancee W, Stevens A, Oldham J, Mosher P. (2002) Psychoanalytic patients in the U.S., Canada and Australia: 1. DSM-III-R disorders, indications, previous treatment, medications, and length of treatment. J. Amer. Psychoanal. Assoc. 50/2 575-614.
Fonagy P (2000) Attachment and Borderline Personality Disorder. J Amer. Psychoanal Assoc. 48/4:1129-1145
Freud S. (1915) Observations on transference love (Further recommendations on the technique of psycho-analysis III) S. E. XII 157-171.
Freud S (1911) Formulations regarding the two principles in mental functioning. S. E. XII pg. 221
Heiman P (1949) On counter-transference. 16th IPA Congress. Zurich 1949
Hesse E and Main M (1999) Second generation effects of unresolved trauma in non-maltreating parents: dissociated frightening and threatening parental behaviour. Psychoanal. Inquiry 19:481-540
Kandel E (1998) A new intellectual framework for Psychiatry. Am. J. Psych. 155:457-469
Kandel E (1999) Biology and the future of psychoanalysis: a new intellectual framework for psychiatry revisited. Amer J Psych. 156:505-524
Kemperman G, Kuhn H, Gage F (1997) More Hippocampal neurons on adult mice living in an enriched environment. Nature 386:493-495
Ladd C, Owens M, Nemeroff C (1996) Persistent changes in corticotropin releasing factor neuronal systems induced by maternal deprivation. Endocrinology. 137:1212-1218
Ladd C. Huot R. Thrivikraman K (2000) Longterm behavioural and neuroendocrine adaption to adverse early experience. Prog. Brain Research. 122:81-103
Linehan M. (1991) Cognitive-behavioural treatment of chronically parasuicical Borderline patients. Arch. Gen. Psychiatry. 48:1060-1064
Linehan M. (1993) Naturalistic follow-up of a behavioral treatment of chronically parasuicidal Borderline patients. Arch. Gen. Psychiatry. 50: 971-974
Lonie I (1999) Unshrinking the hippocampus. In She STILL wont be right mate. Chpt. 10 106-117 PWG, Melbourne.
Main M (2000) The organized catagories of infant, child and adult attachment: flexible vs. inflexible attention under attachment-related stress. J. Am. Psychoanal Assoc 48/4:1056-1096
Rosenblum S, Caplan J, Friedman S, (1984) Adverse early experiences affect nor-adrenergic and serotonin functioning in early primates. Biological Psychiatry. 35:221-227
Schore A (1994) Affect regulation and the origin of the self: the neurobiology of emotional development. Mahwah, NJ: Erlbaum
Schore A (2001) The effect of early relational trauma on right brain development, affect regulation and infant mental health. Inf. Mental Health J. 22(1-2):201-269
Schore A (2001) Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Inf. Mental Health J. 22(1-2) 7-66.
Seigal D (2001) Toward an interpersonal neurobiology of the developing mind: attachment relationships, mindsight, and neural integration. Inf. Mental Health J. 22(1-2): 67-94..
Stein M Kourola C Hanna C (1997) Hippocampal volume in women victimized by childhood sexual abuse. Psychol Med 27:951-959
Van Izjendoorn M (1995) Adult attachment representations, parental responsiveness and infant attachment: a meta analysis on the predictive validity of the Adult Attachment Interview. Psycholog. Bulletin 117: 387-405
Wiesel T (1982) Postnatal development of the visual cortex and the influence of environment. Nature 299:583-591