Personality disorder is a complex and severe mental health issue that is characterised by pervasive and enduring difficulties in intra-personal (e.g. identity, self-worth, accuracy of self-view, self-direction), and inter-personal functioning (e.g., ability to develop and maintain close and mutually satisfying relationships, ability to understand others’ perspectives and to manage conflict in relationships) [1]. These difficulties deviate markedly from the expectations of the individual’s culture and are associated with significant distress or impairment in personal, family, social, educational, occupational or other important spheres [1, 2]. Globally, personality disorder affects 7.8% of the general population [3] and as such, is considered a mental health priority area [4].
Borderline Personality Disorder (BPD), characterised by marked distress caused by intense affectivity and impulsivity, interpersonal difficulties and distorted cognitions [2], is common in primary care and mental health settings. Up to 23% of outpatients and 43% of inpatients in Australian mental health services meet criteria for BPD [5], compared to approximately 0.7-2% of the general global population [6]. Although BPD is thought to occur equally amongst men and women in the general global population [7] women are disproportionately represented in clinical settings, comprising of up to 75% of those given a BPD diagnosis in the United States of America according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) [8]. In the Australian context, recent data from a representative health service found that men and women had similar rates of presentation with a diagnosed personality disorder [9]. However, women were more likely to be referred to a personality disorder service or be offered specialist long-term psychological therapy [9, 10].
For individuals with BPD, emotional dysregulation, high levels of impulsivity (often leading to self-harm and suicidality), and disturbed interpersonal functioning, are thought to lead to difficulties in forming and maintaining inter- and intra-personal relationships [2]. In combination, genetic vulnerability to BPD and negative early experiences with parents and caregivers are considered to put a child at increased risk of developing BPD or experiencing its related features in adulthood [11, 12]. As such, the parent-child relationship is considered an important context for the aetiology and the potential intergenerational transmission of BPD [13].
Parenting challenges associated with borderline personality disorder
Parents with BPD appear to experience additional emotional and behavioural challenges in their parenting role. For these individuals, fluctuations in mental wellbeing, difficulties with expressing appropriate empathic responses, maintaining a stable and safe environment, parent-child role confusion (e.g. parentification of children) and interpersonal conflict appear to exacerbate the everyday challenges of being a parent [14]. Mothers with BPD are considered to be particularly at risk, with this group more likely to demonstrate misattuned speech and behaviour with their infants, including critical, intrusive and frightened or frightening comments and behaviours, and increased role confusion compared to those with depression and healthy controls [15, 16]. Additionally, these parents also differ in their perceptions of their parenting ability. Self-report measures assessing parenting perceptions show that mothers with BPD report less competence (satisfaction and efficacy) and more distress in their parenting role, and it has been hypothesised that these difficulties may inadvertently contribute to a greater likelihood of mothers with BPD struggling with safe parenting of their children [17]. Thus, a mother’s level of distress and sense of competency may profoundly affect parenting capacity and compromise responsiveness and sensitivity to the child.
Children of parents who struggle with personality difficulties, particularly BPD, demonstrate lower Apgar scores, and greater rates of prematurity and special care nursery referral during early infancy compared to controls [18]. Whilst at 12-months of age, infants of mothers with BPD have been found to show lower levels of “availability for positive engagement”, and greater attachment disorganization compared to controls [19]. Young children aged four to seven whose mothers have BPD tell stories that include more parent-child role reversal, fear of abandonment, negative parent-child relationship expectations, incongruent and shameful representations of self and poorer emotion regulation, compared to controls [2]. During adolescence, children aged 11 to 18 years (averaging 15.52 years) of mothers with BPD, have been found to exhibit significantly more emotional (e.g. anxiety/depression, self-esteem and emotional problems more broadly), attentional and behavioural problems (e.g. delinquency, aggression and behavioural problems more broadly), and more suicidal tendencies, than children of mothers with depression only, children of mothers with no psychiatric condition, or children of mothers with ‘cluster C’ personality disorders [14]. Given the range of challenges encountered by parents with personality disorder and the possible impact on their children across various developmental stages, identifying key mechanisms may help to prevent parents inadvertently transferring these difficulties onto the child. There is consequently a great need to further understand and modify the putative intergenerational transmission of personality vulnerabilities.
Potential mechanisms underlying parenting challenges
There are a number of mechanisms that have been hypothesised to underly parenting challenges for individuals with BPD. However, early childhood trauma, attachment and reflectivity capacity or ‘mentalizaton’ have historically received attention in the literature exploring parenting and BPD [13]. Many individuals with BPD (up to 84% in some studies) [21] retrospectively describe experiences of bi-parental neglect and emotional abuse before the age of 18. This history of early trauma may be associated with challenges for individuals with BPD in their own parenting role, particularly for those who find the experience triggers painful memories of early abuse or neglect that they may attempt to overcompensate with “overprotection” [14]. A parent’s history of early trauma may also be associated with negative outcomes for their children. For example, in a recent study [22] of youth brought to the attention of child protective services for history of maltreatment, substance abuse and family violence, 34.3% of mothers had a previous diagnosis or met criteria for BPD. Half of these mothers had also experienced childhood maltreatment and were also investigated by child protective services. Given the elevated rates of childhood abuse and neglect reported by individuals with BPD and the potential for the parent-child relationship to trigger traumatic memories from the parent’s family of origin, it seems plausible that a parent’s recalled trauma history may be associated with their feelings of stress and competence in their parenting role in the present. However, further investigation is needed to support this proposition.
A secure attachment relationship in early childhood is thought to lay the foundation for a child’s capacity to develop secure relationships in adolescence and adulthood, the capacity for emotional regulation and reflectivity capacity. Conversely, if children do not have their attachment needs met or receive inappropriate responses from their caregiver (such as lack of response, inconsistent or abusive responses), they may develop maladaptive internal working models that result in insecure attachment [23]. Individuals with BPD have been found to more frequently endorse insecure attachment styles, particularly preoccupied, fearful or unresolved, than the general population [24]. Moreover, mothers with BPD are more likely to have infants who also exhibit insecure or disorganised attachment styles, with intrusive or insensitive maternal relatedness thought to be a key factor impacting infant attachment organisation [19]. Based on previous research, the manner or quality of a parent’s way of relating to their child may also be influenced by their psychological wellbeing (including their personality difficulties and perceived parenting stress) [16, 17] and their relationship to their self (including their role as a parent and parent-child role confusion) [14]. However, the relationship between attachment and perceptions of parenting stress and competence for individuals with BPD is not yet known. Further investigation may assist us to identify possible mechanisms underlying parentings challenges faced by individuals with BPD.
Impairments in reflective capacity have been implicated in various psychiatric disorders, including BPD [25, 26, 27, 28, 29, 30]. Mentalization or ‘reflective functioning’ is the process through which a person is able to make meaning of their own behaviour and infer the mental states of others (i.e., thoughts, feelings and beliefs) and has been described as the individual’s ability to ‘hold others’ minds in mind’ [31, 32, 33]. In the context of the parent-child relationship, parental reflective capacity or ‘parental reflective functioning’ describes a parent’s capacity to reflect upon their own child’s internal mental experience and to understand behaviour in the light of the child's underlying mental states and intentions, and in doing so ‘hold the child’s mind in mind’ [34, 35]. Parental reflective capacity has been found to be related to mother-infant attachment [36, 37] and sensitive and responsive caregiving [38, 39]. It also seems plausible that a parent’s ability to enter and reflect upon the subjective world of their child may also impact their levels of stress and their feelings of competence in parenting role. However, there is currently a gap in literature in regard to the putative relationship between parenting reflective capacity and perceptions of parenting stress and competence. Through exploring this relationship, we hope to come closer to identifying key mechanisms underlying a small subset of the difficulties that many individuals with BPD face in their parenting role.
The current study
The current study examines how a parent’s subjective rating of their stress and competence may be associated with difficulties in the parent’s life, including their personality and other mental health challenges, their attachment, reflective capacity, and also recalled experiences from their early family environment. In concordance with previous literature demonstrating the challenges faced by individuals with BPD, we hypothesise that:
- Individuals higher in BPD features will report greater parenting stress and lesser parenting competence compared to those lower in BPD features.
- Those higher in BPD features are also hypothesised to report additional challenges, including lesser psychological wellbeing, lesser parental reflective capacity, greater attachment difficulties, and will be more likely to report trauma in their early family environment, compared to those lower in BPD features.
- Taken together, personality difficulties, psychological wellbeing, trauma history, attachment and parental reflective capacity are hypothesised to predict parenting stress and competence for the entire sample.