Advertisement

The Neurobiology of Empathy in Borderline Personality Disorder

  • Luis H. Ripoll
  • Rebekah Snyder
  • Howard Steele
  • Larry J. Siever
Personality Disorders (C Schmahl, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Personality Disorders

Abstract

We present a neurobiological model of empathic dysfunction in borderline personality disorder (BPD) to guide future empirical research. Empathy is a necessary component of interpersonal functioning, involving two distinct, parallel neural networks. One form of empathic processing relies on shared representations (SR) of others’ mental states, while the other is associated with explicit mental state attribution (MSA). SR processing is visceral and automatic, contributing to attunement, but also emotional contagion. MSA processing contributes to deliberate, perspectival forms of empathic understanding. Empathic dysfunction in BPD may involve hyper-reactivity of SR networks and impairment of MSA networks. Nevertheless, this empathic dysfunction is subtle, but contributes to interpersonal difficulties. Interaction between genetic factors and traumatic attachment stressors may contribute to development of BPD, with painful attachment insecurity and disorganization affecting SR and MSA network functioning. Future avenues for BPD research will include developmental assessment of attachment and neurobiological functioning under varying conditions.

Keywords

Borderline personality disorder BPD Personality; Empathy Attachment theory Social cognition Aggression Social affectivity Neuropeptides Neurobiology Psychiatry 

Notes

Disclosure

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

References

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

  1. 1.
    Leiberg S, Anders S. The multiple facets of empathy: A survey of theory and evidence. Prog Brain Res. 2006;156:419–40.PubMedCrossRefGoogle Scholar
  2. 2.
    • Zaki J, Ochsner K. The neuroscience of empathy: progress, pitfalls and promise. Nat Neurosci. 2012;15(5):675–80. This review highlights the need for naturalistic empathy research and summarizes research on SR and MSA processing thus far in nonclinical subjects.PubMedCrossRefGoogle Scholar
  3. 3.
    Beebe B, Lachmann FM. Infant research and adult treatment: Co-constructing interactions. Hillsdale: Analytic Press; 2002.Google Scholar
  4. 4.
    • Decety J, Michalska KJ. Neurodevelopmental changes in the circuits underlying empathy and sympathy from childhood to adulthood. Dev Sci. 2010;13:886–99. This study illustrates key changes in the functioning of empathic circuitry across development.PubMedCrossRefGoogle Scholar
  5. 5.
    Fonagy P, Gergely G, Target M. The parent-infant dyad and the construction of the subjective self. J Child Psychol Psychiatry. 2007;48:288–328.PubMedCrossRefGoogle Scholar
  6. 6.
    Choi-Kain LW, Zanarini MC, Frankenburg FR, et al. A longitudinal study of the 10-year course of interpersonal features in borderline personality disorder. J Pers Disord. 2010;24:365–76.PubMedCrossRefGoogle Scholar
  7. 7.
    Gunderson JG, Lyons-Ruth K. BPD’s interpersonal hypersensitivity phenotype: a gene-environment-developmental model. J Pers Disord. 2008;22(1):22–41.PubMedCrossRefGoogle Scholar
  8. 8.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.Google Scholar
  9. 9.
    Black DW, Blum N, Pfohl B, et al. Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. J Pers Disord. 2004;18:226–39.PubMedCrossRefGoogle Scholar
  10. 10.
    Brodsky BS, Groves SA, Oquendo MA, et al. Interpersonal precipitants and suicide attempts in borderline personality disorder. Suicide Life Threat Behav. 2006;36(3):313–22.PubMedCrossRefGoogle Scholar
  11. 11.
    Jovev M, Jackson HJ. The relationship of borderline personality disorder, life events and functioning in an Australian psychiatric sample. J Pers Disord. 2006;20(3):205–17.PubMedCrossRefGoogle Scholar
  12. 12.
    Bender DS, Skodol AE. Borderline personality as a self-other representational disturbance. J Person Disord. 2007;21:500–17.CrossRefGoogle Scholar
  13. 13.
    Fonagy P, Luyten P. A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Develop Psychopathol. 2009;21:1355–81.CrossRefGoogle Scholar
  14. 14.
    Levy KN, Edell WS, McGlashan TH. Depressive experiences in inpatients with borderline personality disorder. Psychiatr Q. 2007;78:129–43.PubMedCrossRefGoogle Scholar
  15. 15.
    • Steele H, Siever LJ. An attachment perspective on borderline personality disorder: Advances in gene-environment considerations. Curr Psychiatry Rep. 2010;12:61–7. This review summarizes present thinking about gene by environment interactions leading to insecure attachment and borderline personality disorder.PubMedCrossRefGoogle Scholar
  16. 16.
    • Dziobek I, Preissler S, Grozdanovic Z, et al. Neuronal correlates of altered empathy and social cognition in borderline personality disorder. NeuroImage. 2011;57(2):539–48. This neuroimaging study comports specifically with the present model of disturbances in empathic processing in BPD. Borderline subjects demonstrated impairment in MSA regions and hyperactivation of SR regions in a novel empathy paradigm.PubMedCrossRefGoogle Scholar
  17. 17.
    • Hazlett EA, Zhang J, New AS, et al. Potentiated amygdala response to repeated emotional pictures in borderline personality disorder. Biol Psychiatry. 2012;72(6):448–56. This study illustrates amygdala hyper-reactivity and lack of habitation in BPD subjects in response to evaluation of repeated interpersonal stimuli of positive or negative valence (SR hyper-reactivity), along with blunted subjective appraisal of these stimuli (difficulty with empathic deliberation).PubMedCrossRefGoogle Scholar
  18. 18.
    King-Casas B, Sharp C, Lomax-Bream L, et al. The rupture and repair of cooperation in borderline personality disorder. Science. 2008;321:806–10.PubMedCrossRefGoogle Scholar
  19. 19.
    Koenigsberg HW, Fan J, Ochsner KN, et al. Neural correlates of the use of psychological distancing to regulate responses to negative social cues: A study of patients with borderline personality disorder. Biol Psychiatry. 2009;66:354–863.CrossRefGoogle Scholar
  20. 20.
    Mier D, Lis S, Esslinger C, et al. Neuronal correlates of social cognition in borderline personality disorder. Soc Cogn Affect Neurosci. 2012 (epub ahead of print)Google Scholar
  21. 21.
    Minzenberg MJ, Fan J, New AS, et al. Fronto-limbic dysfunction in response to facial emotion in borderline personality disorder: An event-related fMRI study. Psychiatry Rese. 2007;155:231–43.CrossRefGoogle Scholar
  22. 22.
    New AS, Hazlett EA, Newmark RE, et al. Laboratory induced aggression: A positron emission tomography study of aggressive individuals with borderline personality disorder. Biol Psychiatry. 2009;66:1107–14.PubMedCrossRefGoogle Scholar
  23. 23.
    Bateman AW, Fonagy P. Mentalization-based treatment for borderline personality disorder: A practical guide. Oxford: Oxford University Press; 2006.Google Scholar
  24. 24.
    Levy KN, Meehan KB, Kelly KM, et al. Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. J Consul Clin Psychol. 2006;74:1027–40.CrossRefGoogle Scholar
  25. 25.
    Judd PH. Neurocognitive impairment as a moderator in the development of borderline personality disorder. Dev Psychopathol. 2005;17(4):1173–96.PubMedCrossRefGoogle Scholar
  26. 26.
    Ruocco AC, Medaglia JD, Tinker JR, et al. Medial prefrontal cortex hyperactivation during social exclusion in borderline personality disorder. Psychiatry Res. 2010;181(3):233–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Fonagy P, Leigh T, Steele M, et al. The relation of attachment status, psychiatric classification and response to psychotherapy. J Consul Clin Psychol. 1996;64:22–31.CrossRefGoogle Scholar
  28. 28.
    Hesse E. The Adult Attachment Interview: Protocol, method of analysis, and empirical studies. In: Hess E, editor. Handbook of attachment. 2nd ed. New York: Theory, Research, and Clinical Applications. Guilford Press; 2008. p. 552–98.Google Scholar
  29. 29.
    Eisenberg N. Emotion, regulation, and moral development. Ann Rev Psychol. 2000;51:665–97.CrossRefGoogle Scholar
  30. 30.
    Zaki J, Weber J, Bolger N, et al. The neural bases of empathic accuracy. Proc Natl Acad Sci. 2009;106:11382–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Spreng RN, Mar RA, Kim AS. The common neural basis of autobiographical memory, prospection, navigation, theory of mind, and the default mode: a quantitative meta-analysis. J Cogn Neurosci. 2009;21(3):489–510.PubMedCrossRefGoogle Scholar
  32. 32.
    Legrand D, Ruby P. What is self-specific? Theoretical investigation and critical review of neuroimaging results. Psychol Rev. 2009;116:252–82.PubMedCrossRefGoogle Scholar
  33. 33.
    Lieberman MD. Social cognitive neuroscience: A review of core processes. Ann Rev Psychol. 2007;58:259–89.CrossRefGoogle Scholar
  34. 34.
    Tamir DI, Mitchell JP. Neural correlates of anchoring-and-adjustment during mentalizing. Proc Natl Acad Sci U S A. 2010;107(24):10827–32.PubMedCrossRefGoogle Scholar
  35. 35.
    Mitchell JP, Schirmer J, Ames DL, Gilbert DT. Medial prefrontal cortex predicts intertemporal choice. J Cogn Neurosci. 2011;23(4):857–66.PubMedCrossRefGoogle Scholar
  36. 36.
    D’Argembeau A, Feyers D, Majerus S, et al. Self-reflection across time: Cortical midline structures differentiate between present and past selves. Soc Cog Affect Neurosci. 2008;3:244–52.CrossRefGoogle Scholar
  37. 37.
    Mitchell JP, Macrae CN, Banaji MR. Dissociable medial prefrontal contributions to judgments of similar and dissimilar others. Neuron. 2006;50:661.CrossRefGoogle Scholar
  38. 38.
    Powell LJ, Macrae CN, Cloutier J, et al. Dissociable neural substrates for agentic versus conceptual representations of self. J Cogn Neurosci. 2010;22(10):2186–97.PubMedCrossRefGoogle Scholar
  39. 39.
    Otti A, Guendel H, Laer L, et al. I know the pain you feel-how the human brain’s default mode predicts our resonance to another’s suffering. Neuroscience. 2010;169:143–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Zaki J, Hennigan K, Weber J, et al. Social cognitive conflict resolution: Contributions of domain general and domain specific neural systems. J Neurosci. 2010;30:8481–8.PubMedCrossRefGoogle Scholar
  41. 41.
    Minzenberg MJ, Poole JH, Vinogradov S. Social-emotion recognition in borderline personality disorder. Compr Psychiatry. 2006;47:468–74.PubMedCrossRefGoogle Scholar
  42. 42.
    Stillman TF, Baumeister RF, Lambert NM, et al. Alone and without purpose: Life loses meaning following social exclusion. J Exp Soc Psychol. 2009;45:686–94.PubMedCrossRefGoogle Scholar
  43. 43.
    Baumeister RF, Twenge JM, Nuss CK. Effects of social exclusion on cognitive processes: Anticipated aloneness reduces intelligent thought. J Pers Soc Psychol. 2002;83:817–27.PubMedCrossRefGoogle Scholar
  44. 44.
    Cacioppo JT, Norris CJ, Decety J. In the eye of the beholder: Individual differences in perceived social isolation predict regional brain activation to social stimuli. J Cogn Neurosci. 2009;21:83–92.PubMedCrossRefGoogle Scholar
  45. 45.
    Stanley B, Siever LJ. The interpersonal dimension of borderline personality disorder: Toward a neuropeptide model. Am J Psychiatry. 2010;167:24–39.PubMedCrossRefGoogle Scholar
  46. 46.
    Prossin AR, Love TM, Koeppe RA, et al. Dysregulation of regional endogenous opioid function in borderline personality disorder. Am J Psychiatry. 2010;167:925–33.PubMedCrossRefGoogle Scholar
  47. 47.
    Agrawal HR, Gunderson J, Holmes BM, Lyons-Ruth K. Attachment studies with borderline patients: a review. Harv Rev Psychiatry. 2004;12(2):94–104.PubMedCrossRefGoogle Scholar
  48. 48.
    Lemche E, Giampietro VP, Surguladze SA, et al. Human attachment security is mediated by the amygdala: evidence from combined fMRI and psychophysiological measures. Hum Brain Mapp. 2006;27(8):623–35.PubMedCrossRefGoogle Scholar
  49. 49.
    Suslow T, Kugel H, Rauch AV, et al. Attachment avoidance modulates neural response to masked facial emotion. Hum Brain Mapp. 2009;30(11):3553–62.PubMedCrossRefGoogle Scholar
  50. 50.
    Vrticka P, Andersson F, Grandjean D, et al. Individual attachment style modulates human amygdala and striatum activation during social appraisal. PLoS One. 2008;3(8):e2868.PubMedCrossRefGoogle Scholar
  51. 51.
    Harari H, Shamay-Tsoory SG, Ravid M, et al. Double dissociation between cognitive and affective empathy in borderline personality disorder. Psychiatry Res. 2010;175:277–9.PubMedCrossRefGoogle Scholar
  52. 52.
    Preissler S, Dziobek I, Ritter K, et al. Social cognition in borderline personality disorder: Evidence for disturbed recognition of the emotions, thoughts, and intentions of others. Front Behav Neurosci. 2010;4:1–8.CrossRefGoogle Scholar
  53. 53.
    • Daros AR, Zakzanis KK, Ruocco AC. Facial emotion recognition in borderline personality disorder. Psychol Med. 2012 (epub ahead of print). This meta-analysis highlights and summarizes facial emotion recognition findings in BPD, demonstrating distinct difficulties for BPD subjects during processing of ambiguous or socially threatening stimuli.Google Scholar
  54. 54.
    Fertuck EA, Jekal A, Song I, et al. Enhanced ‘Reading the Mind in the Eyes’ in borderline personality disorder compared to healthy controls. Psychol Medicine. 2009;39(12):1979–88.CrossRefGoogle Scholar
  55. 55.
    Lynch TR, Rosenthal MZ, Kosson DS, et al. Heightened sensitivity to facial expressions of emotion in borderline personality disorder. Emotion. 2006;6:647–55.PubMedCrossRefGoogle Scholar
  56. 56.
    Arntz A, Bernstein D, Oorschot M, Schobre P. Theory of mind in borderline and cluster-C personality disorder. J Nerv Ment Dis. 2009;197(11):801–7.PubMedCrossRefGoogle Scholar
  57. 57.
    Ruocco AC, Amirthavasagam S, Choi-Kain LW, McMain SF. Neural correlates of negative emotionality in borderline personality disorder: an activation-likelihood-estimation meta-analysis. Biol Psychiatry. 2012 (epub ahead of print).Google Scholar
  58. 58.
    Romero-Canyas R, Downey G, Berenson K, et al. Rejection sensitivity and the rejection-hostility link in romantic relationships. J Person. 2010;78:119–48.PubMedCrossRefGoogle Scholar
  59. 59.
    Ayduk O, Zayas V, Downey G, et al. Rejection sensitivity and executive control: joint predictors of borderline personality features. J Res Person. 2008;42:151–68.CrossRefGoogle Scholar
  60. 60.
    Berenson KR, Gyurak A, Ayduk O, et al. Rejection sensitivity and disruption of attention by social threat cues. J Res Person. 2009;43:1064–72.CrossRefGoogle Scholar
  61. 61.
    Pickett CL, Gardner WL, Knowles M. Getting a cue: The need to belong and enhanced sensitivity to social cues. Pers Soc Psychol Bull. 2004;30:1095–107.PubMedCrossRefGoogle Scholar
  62. 62.
    Babcock JC, Jacobson N, Gottman J, Yerington TP. Attachment, emotional regulation, and the function of marital violence: differences between secure, preoccupied, and dismissing violent and non-violent husbands. J Family Violence. 2000;15:391–409.CrossRefGoogle Scholar
  63. 63.
    Barnow S, Stopsack M, Grabe HJ, et al. Interpersonal evaluation bias in borderline personality disorder. Behav Res Ther. 2009;47:359–65.PubMedCrossRefGoogle Scholar
  64. 64.
    Stern MI, Herron WG, Primavera LH, et al. Interpersonal perceptions of depressed and borderline inpatients. J Clin Psychol. 1997;53:41–9.PubMedCrossRefGoogle Scholar
  65. 65.
    Westen D, Lohr N, Silk KR, et al. Object relations and social cognition in borderlines, major depressives, and normals: A thematic apperception test analysis. J Consul Clin Psychol. 1990;2:355–64.Google Scholar
  66. 66.
    Domes G, Czieschnek D, Weidler F, et al. Recognition of facial affect in borderline personality disorder. J Pers Disord. 2008;22:135–47.PubMedCrossRefGoogle Scholar
  67. 67.
    von Ceumern-Lindenstjerna IA, Brunner R, Parzer P, et al. Initial orienting to emotional faces in female adolescents with borderline personality disorder. Psychopathology. 2010;43(2):79–87.CrossRefGoogle Scholar
  68. 68.
    Staebler K, Renneberg B, Stopsack M, et al. Facial emotion expression in reaction to social exclusion in borderline personality disorder. Psychol Med. 2011;9:1–10.Google Scholar
  69. 69.
    Holm AL, Severinsson E. The emotional pain and distress of borderline personality disorder: A review of the literature. Int J Mental Health Nurs. 2008;17:27–35.CrossRefGoogle Scholar
  70. 70.
    Rusch N, Lieb K, Gottler I, et al. Shame and implicit self-concept in women with borderline personality disorder. Am J Psychiatry. 2007;164:500–8.PubMedCrossRefGoogle Scholar
  71. 71.
    Stiglmayr CE, Ebner-Priemer UW, Bretz J, et al. Dissociative symptoms are positively related to stress in borderline personality disorder. Acta Psychiatr Scand. 2008;117:139–47.PubMedGoogle Scholar
  72. 72.
    New AS, Rot MA, Ripoll LH, et al. Empathy and alexithymia in borderline personality disorder: clinical and laboratory measures. J Pers Disord. 2012;26(5):660–75.PubMedCrossRefGoogle Scholar
  73. 73.
    Franzen N, Hagenhoff M, Baer N, et al. Superior ‘theory of mind’ in borderline personality disorder: An analysis of interaction behavior in a virtual trust game. Psychiatry Res. 2010;187(1–2):224–33.PubMedGoogle Scholar
  74. 74.
    Bartels A, Zeki S. The neural correlates of maternal and romantic love. NeuroImage. 2004;21:1155–66.PubMedCrossRefGoogle Scholar
  75. 75.
    Cheng Y, Chen C, Lin CP, et al. Love hurts: An fMRI study. NeuroImage. 2010;51:923–9.PubMedCrossRefGoogle Scholar
  76. 76.
    Bartz JA, Zaki J, Bolger N, Ochsner KN. Social effects of oxytocin in humans: Context and person matter. Trend Cogn Sci. 2011;15(7):301–9.Google Scholar
  77. 77.
    Depue RA, Morrone-Strupinsky JV. A neurobehavioral model of affiliative bonding: Implications for conceptualizing a human trait of affiliation. Behav Brain Sci. 2005;28:313–95.PubMedGoogle Scholar
  78. 78.
    Niedtfeld I, Schulze L, Kirsch P, et al. Affect regulation and pain in borderline personality disorder: A possible link to the understanding of self-injury. Biol Psychiatry. 2010;68:383–91.PubMedCrossRefGoogle Scholar
  79. 79.
    Nock MK. Why do People hurt themselves? New insights into the nature and functions of self-injury. Curr Dir Psychol Sci. 2009;18(2):78–83.PubMedCrossRefGoogle Scholar
  80. 80.
    Neumann ID. Brain oxytocin: A key regulator of emotional and social behaviors in both females and males. J Neuroendocrinol. 2008;20:858–65.PubMedCrossRefGoogle Scholar
  81. 81.
    De-Dreu CKW, Greer LL, Handgraaf MJJ, et al. The neuropeptide oxytocin regulates parochial altruism in intergroup conflict among humans. Science. 2010;328:1408–11.PubMedCrossRefGoogle Scholar
  82. 82.
    De-Dreu CKW, Greer LL, van Kleef GA, et al. Oxytocin promotes human ethnocentrism. Proc Natl Acad Sci. 2011;108:1262–6.PubMedCrossRefGoogle Scholar
  83. 83.
    Mobbs D, Yu R, Meyer M, et al. A key role for similarity in vicarious reward. Science. 2009;324:900.PubMedCrossRefGoogle Scholar
  84. 84.
    Bartz JA, Zaki J, Bolger N, et al. Oxytocin selectively improves empathic accuracy. Psychol Sci. 2010;21:1426–8.PubMedCrossRefGoogle Scholar
  85. 85.
    Bartz JA, Zaki J, Ochsner KN, et al. Effects of oxytocin on recollections of maternal care and closeness. Proc Natl Acad Sci. 2010;107:21371–5.PubMedCrossRefGoogle Scholar
  86. 86.
    Bakermans-Kranenburg MJ, van-Ijzendoorn MH, Riem MM, et al. Oxytocin decreases handgrip force in reaction to infant crying in females without harsh parenting experiences. Soc Cogn Affect Neurosci. 2012 (epub ahead of print)Google Scholar
  87. 87.
    van-Ijzendoorn MH, Huffmeijer R, Alink LR, et al. The impact of oxytocin administration on charitable donating is moderated by experiences of parental love-withdrawal. Front Psychol. 2011 (epub ahead of print).Google Scholar
  88. 88.
    Simeon D, Bartz J, Hamilton H, et al. Oxytocin administration attenuates stress reactivity in borderline personality disorder: A pilot study. Psychoneuroendocrinology. 2011;36(9):1418–21.PubMedCrossRefGoogle Scholar
  89. 89.
    Bartz J, Simeon D, Hamilton H, et al. Oxytocin can hinder trust and cooperation in borderline personality disorder. Soc Cogn Affect Neurosci. 2010 (epub ahead of print).Google Scholar
  90. 90.
    Reid VM, Striano T, Iacoboni M. Neural correlates of dyadic interaction during infancy. Dev Cogn Neurosci. 2011;1(2):124–30.PubMedCrossRefGoogle Scholar
  91. 91.
    Brass M, Schmitt RM, Spengler S, et al. Investigating action understanding: Inferential processes versus action simulation. Curr Biol. 2007;17:2117–21.PubMedCrossRefGoogle Scholar
  92. 92.
    Decety J, Moriguchi Y. The empathic brain and its dysfunction in psychiatric populations: Implications for intervention across different clinical conditions. Biopsychosoc Med. 2007;1:22–65.PubMedCrossRefGoogle Scholar
  93. 93.
    Decety J, Michalska KJ, Akitsuki Y. Who caused the pain? A functional MRI investigation of empathy and intentionality in children. Neuropsychologia. 2008;46:2607–14.PubMedCrossRefGoogle Scholar
  94. 94.
    Rothbart MK, Ahadi SA, Hershey KL. Temperament and social behavior in childhood. Merrill-Palmer Quarterly. 1994;40:21–39.Google Scholar
  95. 95.
    Moriguchi Y, Ohnishi T, Mori T, et al. Changes of brain activity in the neural substrates for theory of mind during childhood and adolescence. Psychiatry Clin Neurosci. 2007;61:355–63.PubMedCrossRefGoogle Scholar
  96. 96.
    Steele H, Steele M, Croft C. Early attachment predicts emotion recognition at 6 and 11 years old. Attach Hum Develop. 2008;10:379–93.CrossRefGoogle Scholar
  97. 97.
    Cheng Y, Lin CP, Liu HL, et al. Expertise modulates the perception of pain in others. Curr Biol. 2007;17:1708–13.PubMedCrossRefGoogle Scholar
  98. 98.
    Koenigsberg HW, Fan J, Ochsner KN, et al. Neural correlates of using distancing to regulate emotional responses to social situations. Neuropsychologia. 2010;48:1813–22.PubMedCrossRefGoogle Scholar
  99. 99.
    Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry. 2009;166(12):1355–64.PubMedCrossRefGoogle Scholar
  100. 100.
    Levy KN, Meehan KB, Kelly KM, et al. Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. J Consult Clin Psychol. 2006;74(6):1027–40.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Luis H. Ripoll
    • 1
    • 2
  • Rebekah Snyder
    • 3
  • Howard Steele
    • 4
  • Larry J. Siever
    • 1
    • 5
  1. 1.Department of Psychiatry One Gustave L. Levy PlaceMount Sinai School of MedicineNew YorkUSA
  2. 2.New York Psychoanalytic InstituteNew YorkUSA
  3. 3.Department of PsychologyBarnard College, Columbia UniversityNew YorkUSA
  4. 4.Department of PsychologyNew School for Social ResearchNew YorkUSA
  5. 5.James J. Peters VA Medical CenterMental Illness Research Education and Clinical Center (MIRECC)BronxUSA

Personalised recommendations