Tuesday, May 7, 2019

Personality Disorders: Researchers Continue to Make Misleading Assumptions

In this blog I have discussed several instances of researchers making unwarranted assumptions about both their study populations and in interpreting their results in a variety of ways. In this post, I’d like to focus on three recent articles about personality disorder research. The first is a possible refutation of a common presumption, while the second two assume facts not in evidence.

The difference between “cannot” and “do not:” Confusion based on lack of attention to subject motivation, and ignorance of the concept of “false self.”

Shane MS; Groat LL. “Capacity for upregulation of emotional processing in psychopathy: all you have to do is ask.” Social Cognitive & Affective Neuroscience. 13(11):1163-1176, 2018 11 08.

Could it be that a psychopath’s apparent lack of ability to be empathic stem from differences in motivation rather than ability? This article is certainly possible evidence that this is the case. Perhaps people who routinely engage in anti-social acts suppress empathic responses because that is their role in their family. That what has been observed results from subjects’ false selves

This study of course does not address that latter issue, but thinking about it certainly suggests something which could explain the results. (Of course, it would help in that endeavor if we could read minds, because the thing about a false self is that it is based on someone lying to themselves in order to fulfill a social function, so they are highly unlikely to tell experimenters the truth during a short interview).

In any event, in this study, high-psychopathy participants showed typical, significantly reduced neural responses in the brain on an fMRI to negatively-toned pictures under passive viewing conditions. However, this effect seemed to disappear when the subjects were instructed to try to maximize their naturally occurring emotional reactions to these same pictures!

The locations of these increased neural responses included several brain regions involved in the generation of basic emotional responses and which have often been shown to be reduced in psychopathic populations. Thus, despite baseline differences from non-psychopaths,  high-psychopathy participants appeared capable of deliberately manifesting emotional responses to the negatively toned pictures within several brain regions believed to underlie emotional processing. 

Of note was that the magnitude of these deliberately evoked emotional responses was comparable to levels exhibited by low-psychopathy participants’ during passive processing.

A high index of suspicion versus an “inability” to correctly read the mental states of others

Quek et. al., “Mentalization in Adolescents with Borderline Personality Disorder.: a Comparison with Health Controls.” Journal of Personality Disorders, 33 (2):145-165, April 2018.

Mentalization refers to an individual’s capacity to understand and interpret the meaning of one’s own and others’ behavior by considering underlying thoughts, feelings, intentions, and desire. As in other studies, this was “measured” in adolescent subjects with borderline personality disorder (BPD) and normal controls while interpreting the mental states of others shown in pictures, videos, and narrative vignettes of people in various social situations.

The authors of this paper mention almost in passing that the ability to mentalize  is thought to develop within the context of, and is dependent on, the quality of infant- parent interactions. In the experiment, the differences between the performance of the BPD subjects compared to the control group on the various tests became much greater when the material they interpreted suggested attachment-related stress or arousal. 

Additionally, the major differences between BPD subjects and controls seemed to primarily involve what the authors describe as hypermentalization (that is, making much more complex inferences than expected about social cues, signs, and mental states) by the BPD subjects, rather than through a loss of detail.

Despite all this, the authors don’t seem to consider the obvious possibility that attachment figures’ influence on their children’s ideas about the social behaviors of others continues unabated long after they are no longer infants.

So let’s do a mental experiment. How might you evaluate the motives of other people if you were to grow up in an family environment characterized by your being constantly invalidated and given highly confusing double messages about how you are supposed to think and behave, and even being verbally abused— if not physically or sexually abused—if you seem to have guessed wrong about that? Do you think you might have a higher index of suspicion about other people’s intentions than someone who did not grow up in that environment? Do you think you might have more difficulty making sense of other people's behavior? Ya think??

So, do kids with BPD grow up in that environment? Well, in addition to Linehan’s theory of an invalidating environment being part of the etiology of BPD, and my own paper from 2005 (Comprehensive Psychiatry, 46[5] pp. 340-352) which showed that adults with BPD reported about three times the number of double messages from their parents than non-BPD controls, consider the following paper.

Changing parent’s behavior towards BPD children can make those with BPD better—but their behavior apparently had nothing to do with their kids having developed the disorder in the first place

Grenyer et. al., “A Randomized Controlled Trial of Group Psychoeducation for Carers of Persons with Borderline Personality Disorder.” Journal of Personality Disorders 33 (2):214-228, April 2018.

As mentioned in a post on my blog on Psychology Today, researchers into BPD have of late developed an interest in the “burdens” on parents and other caretakers (almost always other relatives) of having a child or adult child with the disorder. Such “carers” are the subject of this particular study, and were recruited through flyers distributed to mental health services, local media, patient advocacy groups, and patient family and support networks. The recruits were put into groups and given a lot of “psychoeducation” about their charges.

The first thing that jumped out at me in this paper was the fact that, even though the carers were evaluated for being critical and over-involved with their BPD children, there was nothing mentioned about seeing if the parents had been guilty of physically or sexually abusing their charges when the fledgling BPD patients were children. This, despite the fact that every empirical study done on this subject in BPD patients finds a high level of significant abuse history. Of course, parents who respond to flyers and volunteer to be research subjects in this sort of study are highly unlikely to have been seriously abusive. So right away, the experiments are selecting for a somewhat atypical sample of parents of children with BPD.

The second thing that jumped out at me was that the psychoeducation provided for the subjects was supposedly based on Bowen family therapy theory, when the researchers mentioned and seem to know absolutely nothing about one of the major tenets of that theory. You know, those that involve intergenerational transfer of dysfunctional family patterns. The researchers mention nothing about the parents being somewhat responsible for the development of the disorder in their kids in the first place!

That they seem to make this assumption is even more awe-inspiring when you look at what was being taught to the parents and which apparently led to improvement in the BPD child’s behavior as well as in the parent-child relationship. They were taught to:

1.      Be non-judgmental, validating, attentive and appropriate.
2.      Reduce their reactivity and try to remain calm and “mindful.”
3.      Attend to their own needs through staying connected with friends and family, attending to their own physical and mental health, and taking breaks.
4.      Model appropriate assertiveness and setting appropriate boundaries and ground rules for the relationship.
5.      Get outside help when crises arise and having a crisis plan.

So, if they had to be taught these things, and if doing those things leads to improvements in their children, maybe the fact that they were doing the opposite of those things all the time previous to the experiment was what was creating their child’s problems in the first place. Exactly what you would expect considering the family dynamics of BPD.