Attachment, mentalisation and the development of psychiatric disturbance
Prof Anthony W Bateman AAIMH Conference 2008 Adelaide, South Australia
UCL/Anna Freud Centre ¾Prof Peter Fonagy, Dr Mary Target Menninger Department of Psychiatry, Baylor College ¾Dr Efrain Bleiberg, ¾Dr Jon Allen, ¾Dr Brooks King-Casas and Read Montague
Mentalising as social cognition Nature of attachment Neuroimaging and attachment Affect regulation Child abuse and neglect Final link to childhood psychiatric disturbance
What is social cognition?
and justify the actions of others by inferring the intentional mental states that cause them
. explain.How do we understand each other’s actions?
Mentalism: An intuitive ‘theory’ of action Actions are caused by intentional mental states (Beliefs. Wishes) Representation of other minds: Humans can infer. attribute and represent the intentional mental states of others Primary function of mentalizing: Humans can predict. Desires.
In order to adaptively predict and justify each others’ actions
We have to understand that we have
¾SEPARATE MINDS that (often) contain ¾DIFFERENT MENTAL MODELS of reality that cause our Actions.
We have to be able to infer and represent both
¾the MENTAL MODELS of the other’s MIND and ¾the MENTAL MODELS of our own MIND
fantasy) To simultaneously represent and differentiate between the MENTAL MODELS of the SELF and of the OTHER about reality To infer and attribute the mental states of Others from visible behavioural cues as mind states are INVISIBLE To be able to detect our own perceptible ( behavioural.Cognitive Prerequisites for Mentalization
To be able to represent causal mental states of others with COUNTERFACTUAL contents (FALSE BELIEFS) To be able to represent causal mental states of others with FICTIONAL contents (PRETENCE. arousal. and attribute mental states to our Self
.) cues in order to infer. emotional. etc. imagination. physiological. interpret.
Approaches to mentalisation
Understanding others from the inside and oneself from the outside Having mind in mind Mindfulness of minds Understanding misunderstanding
Mentalisation and conceptual cousins
Component Mindfulness Psychological Mindedness Implicit No No Empathy Affect consciousness No
Selforientated Other orientated Cognitive/ Affect
Demonstrates a critical set of relations between feeling and thought Implicates the basis of disorders of emotion as occurring in the same neural systems
.Emotion and Mentalization
The majority of brain structures subserving mentalization are also implicated in the processing of emotions.
Bilateral anterior cingulate .Baron-Cohen’s (2005) model of the social brain The Intention Detector
The Emotion Detector .Superior temporal gyrus Eye Direction Detector .Fusiform gyrus .Mirror neurons .Left inferior frontal gyrus .Body of caudate nucleus The Empathising System .Posterior superior temporal sulcus
Shared Attention Mechanism
.Bilateral anterior cingulate .Orbito-frontal cortex Theory of Mind Mechanism .inferior frontal cortex .Medial prefrontal cortex .Right medial prefrontal cortex .Amygdala .Superior temporal gyrus .Temporo-parietal junction
.Medial prefrontal cortex .
The Nature of Attachment
John Bowlby’s Discovery: The Nature of the Attachment System
Universal human need to form close affectional bonds Extended period of immaturity Î attachment as a behavioral system triggered by fear to ensure the safety of offsprings Reciprocity: attachment behaviours of infants are reciprocated by adult caregiving behaviours → creates attachment to particular adult
Affectional bond: expectation of being offered care
.holding .touching .Bowlby’s Attachment Theory
Need of human infant to seek protection and security through physical contact with the caregiver Attachment system Caregiving system Attachment behaviours Caregiving behaviours
¾ proximity seeking ¾ clinging ¾ smiling .
self-sufficient individual ¾can afford to treat others with coldness or callousness in dependent relationships
.Categories of Adult Attachment
¾internalised sense of being worthy of care ¾effective in eliciting care ¾general sense of efficacy ¾control in dealing independently with stress
¾distrust of emotional and social support ¾superficially positive view of the self as independent.
Categories of Adult Attachment (linked to BPD)
¾doubts about one’s ability to cope ¾greater hope of being assisted by others ==> excessive care-seeking at times of stress ¾greater than average fear of loss of support
Fearful or disorganised attachment
¾associated with inter-personal suspicion. anxiety. self-consciousness and confusion ¾linked to unresolved trauma histories ¾unresolved mourning
Attachment as an Addiction
MacLean (1990) speculated that substance abuse and drug addiction were attempts to replace opiates or endogenous factors normally provided by social attachments Panksepp (1998) a common neurobiology to
¾ mother–infant. ¾ infant–mother. and ¾ male–female attachment
Insel (2003) “Social attachment is an addictive disorder?”
The mesocorticolimbic dopaminergic reward circuit in addiction process
Amygdala/ bed nucleus of ST
Schematic Representation of Attachment Related Brain Activation
Interface of mood. (long term) memory and cognition
Social trustworthiness negative affect and mentalising
Intersubjectivity and Affect Regulation
The disorganisation of the self
Consistent finding from attachment and BPD studies is association between unresolved/disorganised attachment and BPD (Fonagy et al.. ¾ Carlson et al. Patrick at al. 1994. 1996.... (2003) early neglect and maltreatment Î self-injurious behaviour
. Stalker & Davies.(2005) 18 year study of mothers and infants found BPD symptoms in young adulthood o to be predicted by early maltreatment (50% vs 9%) o mother-infant disrupted communication (40% vs 12%) weakly associated with disorganized attachment o The strongest correlation reported was between inappropriate maternal withdrawal from her infant and borderline symptoms in her child 17 years later. 1995) Longitudinal findings
¾ Lyons-Ruth et al.
playful interaction with the caregiver leads to the integration of primitive modes of experiencing internal reality Î mentalization
.Theory: Birth of the Agentive Self
Attachment figure “discovers” infant’s mind (subjectivity)
Internalization Representation of infant’s mental state
Core of psychological self
Infant internalizes caregiver’s representation to form psychological self Safe.
The Development of Affect Regulation
Closeness of the infant to another human being who via contingent marked mirroring actions facilitates the emergence of a symbolic representational system of affective states and assists in developing affect regulation (and selective attention) Î secure attachment For normal development the child needs to experience a mind that has his mind in mind
¾Able to reflect on his intentions accurately ¾Does not overwhelm him ¾Not accessible to neglected children
Symbolization of Emotion
Physical Self: Primary Representations
Constitutional self in state of arousal
bal r e v n no sion s e r p x e
With apologies to Gergely & Watson (1996)
Fonagy..The development of regulated affect
Psychological Self: 2nd Order Representation
Representation of self-state: Internalization of object’s image
ent disp e xp lay r e met s abo sion o f lize d af fect symbolic binding of internal state c on ting
…. Jurist & Target (2002)
.2 0 Mother accessible Mother stillface Mother accessible again Disorganized (n=20)
Average % looking at self
(Gergely. 2004) F(interaction)=12.137. df=2.8 0. Koos.4 0. Fonagy.8 1.4 1.6 1.2 1 0.Duration of Looking at Self During Three Phases of Modified Still Face Procedure
Organized (n=119) 1.6 0.00. et al. p<..
.8 0.4. p<. Fonagy et al.4 0.6 0. Koos..High and low marked mirroring by mothers in the MIS (6m) predicting the creative use of pretence (3 years)
Low in marked mirroring (n=64)
High in marked mirroring (n=69)
Creative use of pretence
1 0. 2006)
Borderline Traits and Quality of Infant Care: Clinical Referral (Lyons-Ruth) Infancy Referral vs Young Adult Comparison: 100%
X2 = 15.64*
Young Adult Comparison Families N = 56
Infancy Comparison Families N = 20
Infancy Early Referral Families N = 22
% D isp layin g B o rd erlin e T raits
80% 60% 40% 20% 0%
Infancy Referral vs Infancy Comparison: X2 = 7.
N=42) = 3. p<.31. OR = 5. Phi = .Borderline Traits and Quality of Infant Care: Maternal Disrupted Affective Communication (Lab Assessment)
% of Young Adult displaying Borderline Traits
80% 60% 40%
Not Disrupted Affective Communication
Disrupted Affective Communication
. based on the relation between abuse and borderline traits.Specific Hypothesis
Borderline traits would be most strongly related to negative and intrusive maternal behavior.
(Gender and demographic risk controlled.f.38 1.41 2.29 .00
d.08 .06 .10 .38 1.54 .22 .38
.90* 1.38 1.
1.Borderline Traits and Subtypes of Maternal Disrupted Affective Communication
N = 42.
Variance accounted for
Affective errors Role confusion Disorientation Intrusive/Negative Withdrawal
By young adulthood. those with borderline traits were more likely to take on undue responsibility for structuring and managing a conflict discussion with the parent. in particular. seems to be a potent contributor to impulsive self damaging behavior. and parents were more likely to be rated highly on role-confusion.The Evolving Story
Quality of early care has enduring and independent effects on young adult affect regulation ¾ not mediated by genetic stress vulnerability ¾ not mediated by later trauma Maternal withdrawal from attachment cues.
. leading to the organization of caregiving-containing attachment stances by adolescence.The Evolving Story…
It may be that maternal withdrawal draws the child into increasingly taking over the responsibility for maintaining the relationship.
Infant’s smiling (?constitution) matters – engages the parent’s caregiving (attachment) system Securely attached parents may not need such strong reward to be engaged Parent’s engagement with marked mirroring is essential for affect regulation May also be important for symbolisation
Attachment Disorganisation in Maltreatment
Exposure to maltreatment
Activation of attachment
The ‘hyperactivation’ of the attachment system
Vinden. 1999. emotionally coaching parents correlate with peer relationships and emotional understanding The inclination of mothers to take the psychological perspective of their child. including maternal mindmindedness and reflective function in interacting with or describing their infants (Fonagy. 2003. Cassidy et al. Fonagy. Meins et al. 1994) Affectively +ve.. et al. 2005. Fonagy & Target. and parental questioning How the other Feels within disciplinary situations Other features of the emotional climate within the family (e. Sharp.. & Parkin. Zoller. Slade.g. 1996. 2006)
. 1997. Fradley. Steele & Holder.. Denham. 2003. 2002. 1992. older siblings. Meins. & Couchoud. Peterson & Slaughter. Perner. Steele. & Goodyer.Environmental Influences on the Development of Social Cognition
Maternal disciplinary style (Ruffman. 2001) – age. Wainwright. Das Gupta. Fernyhough..
2004. & Charman. 1997. Ontai & Thompson. Croft. 2000.Range of Environmental Influences on the Development of Social Cognition The quality of children’s primary attachment relationship facilitates theory of mind development leading to passing standard theory of mind tasks somewhat earlier (e. de
Rosnay & Harris. & Fonagy.g. Meins. Thompson. Fonagy. & Clark-Carter. Fonagy & Target. 1999. 2002. Steele. Fernyhough. 2002)
¾ Not all studies find this relationship and it is more likely to be observed for emotion understanding then ToM
. 2006. 1997 Harris.. 1999. Raikes & Thompson. 1998. Steele. Symons. Russell. Redfern.
Delayed theory-of-mind understanding Failure to understand the situational determinants of emotions
.Inhibition of social understanding associated with maltreatment can lead to exposure to further abuse
Exposure to maltreatment
Intensification of attachment
Inhibition of mentalisation
Inaccurate judgements of facial affects.
Anxiety disorders Disruptive behaviour disorders Depression Emerging borderline personality disorder
. 3. 2.Social cognition and childhood psychiatric disorders
g. agreeing with what others say to ingratiate oneself with them.. making up excuses before an event where poor performance is expected) (Banerjee. 2006)
.Social Cognition in Anxiety
Anxious children have no basic difficulty in in understanding mental states but they have specific difficulties with understanding and effectively managing social situations involving multiple mental states and potential social-evaluative threat Demonstrated connections between mentalising skills and social functioning (Sutton et al. 1999) Social anxiety associated with crude selfpresentation strategies (e.
In hard to manage kids (at age 2.Social Cognition in Disruptive Behaviour Disorder
No simple relation between DBD and ToM for ADHD (Charman. Perner. 1996)
¾Ringleader bullies have superior ToM (Sutton. & Barchfield. 1999a. 2002) or CD (Happe & Frith.3 & 4) ToM and emotion understanding shows relationship to mother-child connectedness (Hughes & Ensor. in press)
¾Harsh parenting most strongly related to DBD in low social cognition group
. Smith & Swettenham. Carroll. & Sturge.
Social Cognition Model of DBD
Disruptive Behaviour Disorder (with Adults)
Executive Functioning Deficit
Strengths in in Social Cognition
Maternal Negativity (harsh parenting)
Blumberg et al.. Sowell et al. 1999. brooding) Î’pseudomentalizing’ (early subjectivity)
Differential maturation of brain regions (Casey.. Giedd.. 2000. 2004)
.Social Cognition in Depression
Well documented abnormalities of social information processing
¾ Distortions of socio-cognitive knowledge structures
o Negative self-schema o Negative self-concept
¾ Social-cognitive processing impairments
o Engaging in self-focused ruminative thinking (reflection vs. 2004)
¾ Potential abnormalities in frontal regions may not become apparent until later adolescence/early adulthood (Blumberg et al. 2004.
relational aggression. 2006)
. 2005) Mentalizing deficit associated with BPD in young adults (Fonagy et al. affect negativity. relational aggression.Social Cognition in Emergent Borderline PD
Cross sectional study of BPD precursors (affect lability. suicidal ideation. disliked) in 360 school age children predicted independently by maltreatment and attention task requiring resolution of conflicting cues (Rogosch & Cicchetti. self-harm. conflicted relationships.. 2005) Two year prospective study of developmental precursors of BPD features in a representative sample of 400 4th-6th graders showed moderate stability and identified unique social cognitive indicators (friend exclusivity. cognitive sensitivity) when controlling for depression (Crick. Murray-Close & Woods. preoccupied attachment.
Mean Eyes Scores of BPD (n=25) Cluster A/B (n=25). Allen & Vrouva. Axis-I (n=24) and non-Psychiatric Controls (n=25)
Mean Eyes Scores
0 Patients with BPD diagnosis Non-psychiatric controls Axis-I controls Axis-II controls
. Stein.95) = 6.
Dickhaut & McCabe (Games and Economic Behavior.A dynamic version of the Trust game (10 rounds) BPD: The absence of Basic Trust
King-Casas. (Econometrica. Lomax and Montague (in preparation)
Camerer & Weigelt. Sharp. 1995)
. Fonagy. 1988) Berg.
MU sent / MU available
40% 30% 20% 10% 1 2 3 4 5 6 7 8 9 10
26 non-psychiatric investors 42 non-psychiatric investors
60% 50% 40% 30% 20% 10%
MU sent / MU available
26 non-psychiatric trustees 42 BPD trustees
*King-Casas et al.
What are the dynamics between partners that could result in decreasing cooperation in NC/BPD dyads?
both groups ‘punish’ betrayals similarly
positive investor reciprocity
4. Science 2008
0. controls strongly incentive further increases in cooperation. *King-Casas et al. while BPDs do not.13
controls ‘reward’ benevolence more than BPDs
Thus.How do investor variables predict changes in repayment by group?*
Controls negative investor reciprocity
change in investment ratio
(N = 60)
r = +. making the investment level dangerously low.004
(N = 50) +1
r = +.002
(N = 65)
change in repayment ratio
*King-Casas et al. p < .’ trustees give back more – rewarding their partner’s generosity
when investments decrease.Normal Controls
Change in Investment x Change in Repayment
when investments increase into the ‘high range. p < .38. trustees give back more – ‘cry uncle’
r = -.18.
(N = 72)
change in repayment ratio
*King-Casas et al. ns
(N = 108) +1
r = -.08. ns
(N = 94)
r = +. in preparation
change in investment ratio
Change in Investment x Change in Repayment
BPDs don’t ‘reward’ investments increases
BPDs don’t ‘forgive’ investments decreases
r = .
g. ASD) Over-activation and distorted use of mentalization (as in paranoid and delusional thought pathologies): e.g. Childhood Autism. Borderline Personality Disorder Reality Distorting dysfunctional mentalization processes resulting in distorted representations of the other’s (or the self’s) mind states
¾ Inability to distinguish audience’s known preferenceÎ Anxiety ¾ Ruminative self-referential thinking Î Depression
Mentalization as protective factor
¾ Failure to protect from harsh parenting Î DBD
.g. Schizophrenia Context-specific inhibition of the ability to mentalize in emotionally highly charged intimate interpersonal relationships and situations: e.What kinds of distortions of mentalization do we find in psychopathological disorders?
Lacking the ability to represent other minds (e.
The story so far..
Mentalizing is very early Dysfunctions of mentalizing are very likely to be entailed in a range of different pathologies of childhood (not just childhood autism and schizophrenia) Individual differences in mentalizing are not primarily genetic The capacity for mentalization may be both facilitated and undermined by family relationships Mentalizing may be a key mechanism through which influential (protective and risk associated) aspects of family environment make themselves felt in the formation of childhood disturbances If so then social cognition may be an important focus for treatment and prevention
Thank you for mentalizing!