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Attachment,

mentalisation and the

development of

psychiatric disturbance

Prof Anthony W Bateman AAIMH Conference 2008

Adelaide, South Australia



Acknowledgments

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



Overview

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?



How do we understand each other’s actions?

Mentalism: An intuitive ‘theory’ of action

Actions are caused by intentionalmental states (Beliefs, Desires,

Wishes)

Representation of other minds:Humans can infer, attribute and

represent the intentional mental states

of others

Primary function of mentalizing:

Humans can predict, explain, and

justify the actions of others by

inferring the intentional mental states

that cause them



In order to adaptively predict and justify

each others’ actions We have to understand that we have

¾SEPARATE MINDS that (often) contain¾DIFFERENT 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



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 otherswith FICTIONAL contents (PRETENCE, imagination,

fantasy)

To simultaneously represent and differentiate betweenthe MENTAL MODELS of the SELF and of the OTHERabout reality

To infer and attribute the mental states of Others fromvisible behavioural cues as mind states are INVISIBLE

To be able to detect our own perceptible ( behavioural,

physiological, emotional, arousal, etc.) cues in order toinfer, interpret, and attribute mental states to our Self



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

Empathy Affect

consciousness

Implicit No No Yes No

Explicit Yes Yes Yes Yes

Self-

orientated

Yes Yes Minimal Yes

Other

orientated

No Minimal Yes Yes

Cognitive/ Affect

Cog=Affect Cog=Affect Affect>Cog Affect>Cog



Emotion and Mentalization The majority of brain structures subserving

mentalization are also implicated in theprocessing of emotions.

Demonstrates a critical set of relationsbetween feeling and thought

Implicates the basis of disorders of

emotion as occurring in the same neural

systems



Baron-Cohen’s (2005) model of the

social brainThe Emotion Detector - Left inferior frontal gyrus

- Mirror neurons

The Intention Detector - Right medial prefrontal cortex

- inferior frontal cortex

- Bilateral anterior cingulate

- Superior temporal gyrus

Eye Direction Detector - Posterior superior

temporal sulcus

Shared Attention Mechanism

- Bilateral anterior cingulate- Medial prefrontal cortex

- Body of caudate nucleus

The Empathising System- Fusiform gyrus

- Amygdala

- Orbito-frontal cortex

Theory of Mind Mechanism- Medial prefrontal cortex

- Superior temporal gyrus

- Temporo-parietal junction

EMOTION UNDERSTANDING BELIEF-DESIRE REASONING



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 immaturityÎ

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→ createsattachment to particular adult



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 Caregivingbehaviours

¾proximity seeking - touching

¾clinging - holding

¾smiling - soothing

Affectional bond: expectation of being offered

care



Categories of Adult Attachment Secure attachment

¾internalised sense of being worthy of care

¾effective in eliciting care¾general sense of efficacy

¾control in dealing independently with stress

Dismissing attachment

¾distrust of emotional and social support

¾superficially positive view of the self as

independent, self-sufficient individual

¾can afford to treat others with coldness or callousness in dependent relationships



Categories of Adult Attachment (linked to BPD)

Preoccupied attachment

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 toreplace opiates or endogenous factors normally

provided by social attachments

Panksepp (1998) a common neurobiology to

¾mother–infant,

¾infant–mother, and

¾male–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 trustworthinessnegative affect

and mentalising

Attachment

System

(-) (-)

System BSystem A



Intersubjectivity

and Affect

Regulation



The disorganisation of the self

Consistent finding from attachment and BPD studiesis association between unresolved/disorganisedattachment and BPD (Fonagy et al., 1996; Patrick at

al., 1994; Stalker & Davies, 1995) Longitudinal findings¾Lyons-Ruth et al.,(2005) 18 year study of mothers and

infants found BPD symptoms in young adulthoodo 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 betweeninappropriate maternal withdrawal from her infant andborderline symptoms in her child 17 years later.

¾Carlson et al., (2003) early neglect and maltreatment Îself-injurious behaviour



Theory: Birth of the Agentive Self

Attachment figure “discovers” infant’s mind (subjectivity)

Representation of

infant’s mental

state

Attachment figure Infant

Core of psychological

self

Internalization

Inference

Infant internalizes caregiver’s representation to form psychological self Safe, playful interaction with the caregiver leads to the integration of primitive

modes of experiencing internal realityÎ mentalization



The Development of Affect Regulation

Closeness of the infant to another humanbeing who via contingent marked mirroring

actions facilitates the emergence of asymbolic representational system of affectivestates and assists in developing affect

regulation (and selective attention) Î secureattachment

For normal development the child needs toexperience a mind that has his mind in mind

¾ Able to reflect on his intentions accurately

¾Does not overwhelm him¾Not accessible to neglected children



Psychological

Self:

2nd Order

Representation

Physical Self:

Primary

Representations

Representation

of self-state:

Internalization

of object’s image

Constitutional self

in state of arousal

Expression

Reflection

Resonance

Infant CAREGIVER

symbolic binding

of internal state

c o n t i n g e n t d i s p l a y e x p r e s s i o n o f

m e t a b o l i z e d a f f e c t

s ig n a l

n o n - v e r b a l

e x p r e s s i o n

The development of regulated affect

…..Symbolization of Emotion

With apologies to Gergely & Watson (1996)Fona Ger el Jurist & Tar et 2002



Duration of Looking at Self During Three Phases

of Modified Still Face Procedure

0

0.20.4

0.6

0.8

1

1.2

1.4

1.61.8

Mother accessible Mother stillface Mother accessible

again

Organized (n=119) Disorganized (n=20)

F(interaction)=12.00, df=2,137, p<.0001(Gergely, Fonagy, Koos, et al., 2004)

A v e r a

g e

%

l o o

k i n

g a

t s e

l f



High and low marked mirroring by mothers in the MIS

(6m) predicting the creative use of pretence (3 years)

0

0.2

0.4

0.6

0.8

1

1.2

Low in marked mirroring (n=64) High in marked mirroring (n=69)

(Gergely, Koos, Fonagy et al., 2006)

C r e

a t i v e

u s e o

f p r

e t e

n c e

Mann-Whitney=196, z=2.4, p<.006

B d li T it d Q lit f I f t C



Borderline Traits and Quality of Infant Care:

Clinical Referral (Lyons-Ruth)

13% 9%

40%

0%

20%

40%

60%

80%

100%

%

D

i s p l a y i n g

B o r d e r l i n e T

r a i t s

Young Adult Comparison

Families

Infancy Comparison

Families

Infancy Early Referral

FamiliesN = 56 N = 20 N = 22

Infancy Referral vs Young Adult Comparison:X2 = 15.30***

Infancy Referral vs Infancy Comparison:

X2 = 7.64*

Borderline Traits and Quality of Infant Care: Maternal



Borderline Traits and Quality of Infant Care: Maternal

Disrupted Affective Communication (Lab Assessment)(Karlen Lyons-Ruth)

12%

40%

0%

20%

40%

60%

80%

100%

%

o f Y o u n g A

d u l t d i s p l a y i n g

B o r d e r l i n e T r a i t s

Not Disrupted Affective

Communication

Disrupted Affective

Communication

X² (1, N=42) = 3.95, p<.05, Phi = .31, OR = 5.0



Specific Hypothesis

Borderline traits would be most strongly

related to negative and intrusive maternalbehavior, based on the relation between

abuse and borderline traits.

30



Borderline Traits and Subtypes of Maternal Disrupted

Affective Communication

X² d.f. R Variance

accounted for

Affective errors 1.41 1,38 .22

Role confusion 2.54 1,38 .29

Disorientation .10 1,38 .08

Intrusive/Negative .00 1,38 .06

Withdrawal 5.90* 1,38 .42 18%

(Gender and demographic risk controlled.)

N = 42.

Th E l i St



The Evolving Story

Quality of early care has enduring and independenteffects on young adult affect regulation

¾not mediated by genetic stress vulnerability

¾not mediated by later trauma

Maternal withdrawal from attachment cues, inparticular, seems to be a potent contributor to impulsiveself damaging behavior.

By young adulthood, those with borderline traits weremore likely to take on undue responsibility for structuring and managing a conflict discussion with the

parent, and parents were more likely to be rated highlyon role-confusion.



The Evolving Story…

It may be that maternal withdrawal draws

the child into increasingly taking over theresponsibility for maintaining the

relationship, leading to the organization of caregiving-containing attachment stances

by adolescence.

E l i St



Evolving Story

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

Trauma



Attachment Disorganisation in Maltreatment

DISTRESS/FEAR

Exposure to maltreatment

Proximity seeking

Activation of attachment

The ‘hyperactivation’ of the attachment system

Environmental Influences on the Development of Social



Environmental Influences on the Development of Social

Cognition

Maternal disciplinary style (Ruffman, Perner, &Parkin, 1999; Vinden, 2001) – age, older siblings, andparental questioning How the other Feels within

disciplinary situations Other features of the emotional climate within the

family (e.g., Cassidy et al., 1992; Denham, Zoller, &Couchoud, 1994) Affectively +ve, emotionally coaching

parents correlate with peer relationships and emotionalunderstanding

The inclination of mothers to take the psychological

perspective of their child, including maternal mind-mindedness and reflective function in interactingwith or describing their infants (Fonagy, Steele,Steele & Holder, 1996; Fonagy & Target, 1997; Meins et

al., 2003; Meins, Fernyhough, Wainwright, Das Gupta,Fradley, et al., 2002; Peterson & Slaughter, 2003;Slade, 2005; Sharp, Fonagy; & Goodyer, 2006)

Range of Environmental Influences on the



Range of Environmental Influences on the

Development of Social Cognition The quality of children’s primary attachment

relationship facil itates theory of mind

development leading to passing standardtheory of mind tasks somewhat earlier (e.g., de

Rosnay & Harris, 2002; Fonagy & Target, 1997;

Fonagy, Redfern, & Charman, 1997 Harris, 1999;

Meins, Fernyhough, Russell, & Clark-Carter, 1998;

Raikes & Thompson, 2006; Steele, Steele, Croft, &

Fonagy, 1999; Symons, 2004; Thompson, 2000;

Ontai & Thompson, 2002)

¾Not all studies find this relationship and it is more likely tobe observed for emotion understanding then ToM

Inhibition of social understanding associated with



Inhibition of social understanding associated with

maltreatment can lead to exposure to further abuse

DISTRESS/FEAR

Exposure to maltreatment

Inhibition of mentalisation

Intensification of attachment

Inaccurate judgements of facial affects,Delayed theory-of-mind understanding

Failure to understand the situational determinants of emotions



Social cognition andchildhood psychiatric

disorders

1. Anxiety disorders

2. Disruptive behaviour disorders

3. Depression

4. Emerging borderline personalitydisorder

S i l C iti i A i t



Social Cognition in Anxiety

Anxious children have no basic difficulty in in

understanding mental states but they have specific

difficulties with understanding and effectivelymanaging social situations involving multiplemental states and potential social-evaluative threat

Demonstrated connections between mentalisingskills and social functioning (Sutton et al., 1999)

Social anxiety associated with crude self-

presentation strategies (e.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 Disruptive Behaviour



Social Cognition in Disruptive Behaviour

Disorder No simple relation between DBD and ToM

for ADHD (Charman, Carroll, & Sturge, 2001;

Perner, Kain, & Barchfield, 2002) or CD(Happe & Frith, 1996)

¾Ringleader bullies have superior ToM (Sutton,Smith & Swettenham, 1999a,b)

In hard to manage kids (at age 2,3 & 4) ToM

and emotion understanding showsrelationship to mother-child connectedness(Hughes & Ensor, in press)

¾Harsh parenting most strongly related to DBD inlow social cognition group



Social Cognition Model of DBD

Strengths inin Social Cognition

ExecutiveFunctioning

Deficit

Maternal Negativity

(harsh parenting)

Disruptive

Behaviour Disorder

(with Adults)

Social Cognition in Depression



Social Cognition in Depression

Well documented abnormalities of social informationprocessing¾Distortions of socio-cognitive knowledge structures

o Negative self-schema

o Negative self-concept

¾Social-cognitive processing impairments

o Engaging in self-focused ruminative thinking (reflection vs.brooding)Î’pseudomentalizing’ (early subjectivity)

Differential maturation of brain regions (Casey,

1999; Sowell et al., 2000; Blumberg et al., 2004;Giedd, 2004)¾Potential abnormalities in frontal regions may not become

apparent until later adolescence/early adulthood(Blumberg et al., 2004)

Social Cognition in Emergent Borderline PD



Social Cognition in Emergent Borderline PD

Cross sectional study of BPD precursors (affect lability,

affect negativity, self-harm, suicidal ideation, preoccupied

attachment, relational aggression, conflicted relationships,

disliked) in 360 school age children predictedindependently by maltreatment and attention task requiring

resolution of conflicting cues (Rogosch & Cicchetti, 2005)

Two year prospective study of developmental precursorsof BPD features in a representative sample of 400 4th-6th

graders showed moderate stability and identified unique

social cognitive indicators (friend exclusivity, relationalaggression, cognitive sensitivity) when controlling for

depression (Crick, Murray-Close & Woods, 2005)

Mentalizing deficit associated with BPD in young adults(Fonagy et al., 2006)

Mean Eyes Scores of BPD (n=25) Cluster A/B (n=25)



(Fonagy, Stein, Allen & Vrouva, 2005)

Mean Eyes Scores of BPD (n=25) Cluster A/B (n=25),

Axis-I (n=24) and non-Psychiatric Controls (n=25)

0

5

10

15

20

25

30

Patients with BPD

diagnosis

Non-psychiatric

controls

Axis-I controls Axis-II controls

M e a n E y

e s S c o r e s

F(3,95) = 6.1, p<.001

A dynamic version of the Trust game (10 rounds)



y g ( )

BPD: The absence of Basic Trust

X 3

$20

Investor TrusteeCamerer & Weigelt, (Econometrica, 1988)

Berg, Dickhaut & McCabe (Games and Economic Behavior, 1995)

King-Casas, Fonagy, Sharp, Lomax and Montague (in preparation)



60%

50%

40%

30%

20%

10%1 3 4 7 95 6 8 102

Investor SentMU sent / MU available

26 non-psychiatric investors

42 non-psychiatric investors

60%

50%

40%

30%

20%

10%1 3 4 7 95 6 8 102

Trustee RepaidMU sent / MU available

26 non-psychiatric trustees42 BPD trustees

rounds*King-Casas et al, in preparation



What are the dynamics between partners that could

result in decreasing cooperation in NC/BPD dyads?



How do investor variables predict changes in repayment by group?*

Controls BPD

negativeinvestor reciprocity

0.32 0.32

p 4.0E-03 2.9E-04

(79) (100)

positive

investor reciprocity0.43 0.13

p 1.8E-04 ns

(72) (121)

both groups ‘punish’

betrayals similarly

controls ‘reward’

benevolence more than

BPDs

Thus, controls strongly incentive further

increases in cooperation, while BPDs do not.

*King-Casas et al, Science 2008

Normal Controls



Change in Investmentx Change in Repayment

when investments increase into the

‘high range,’ trustees give back more –

rewarding their partner’s generosity

when investments decrease, making the

investment level dangerously low,

trustees give back more – ‘cry uncle’

r = -.39, p < .004(N = 50)

-1 0 +1 -1

+1

-1

0

cha

c

h a n g e i n r e p a y m e

n t r a t i o

r = +.18, ns(N = 60)

r = +.38, p < .002(N = 65)

0 +1 -1 0 +1

nge in investment ratio*King-Casas et al, in preparation

BPD group



Change in Investmentx Change in Repayment

BPDs don’t ‘reward’

investments increases

BPDs don’t ‘forgive’

investments decreases

r = .00, ns(N = 108)

-1 0 +1 -1

+1

-1

0

cha

c

h a n g e i n r e p a y m e

n t r a t i o

r = -.08, ns(N = 94)

r = +.06, ns(N = 72)

0 +1 -1 0 +1

nge in investment ratio*King-Casas et al, in preparation

What kinds of distortions of mentalization do we find

i h h l i l di d ?



in psychopathological disorders? Lacking the abili ty to represent other minds (e.g.

Childhood Autism, ASD)

Over-activation and distorted use of mentalization (as in

paranoid and delusional thought pathologies): e.g.Schizophrenia

Context-specific inhibition of the abili ty to mentalize inemotionally highly charged intimate interpersonalrelationships and situations: e.g. Borderline PersonalityDisorder

Reality Distorting dysfunctional mentalization processes

resulting in distorted representations of the other’s (or theself’s) mind states¾ Inability to distinguish audience’s known preferenceÎ Anxiety

¾ Ruminative self-referential thinkingÎ Depression

Mentalization as protective factor ¾ Failure to protect from harsh parentingÎ DBD

The story so far..



y

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 andschizophrenia)

Individual differences in mentalizing are notprimarily genetic

The capacity for mentalization may be bothfacilitated and undermined by family relationships

Mentalizing may be a key mechanism throughwhich influential (protective and risk associated)aspects of family environment make themselvesfelt in the formation of childhood disturbances

If so then social cognition may be animportant focus for treatment and prevention



Thank you for mentalizing!

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