Bo and Kongerslev Borderline Personality Disorder

and Emotion Dysregulation (2017) 4:4

DOI 10.1186/s40479-017-0055-7

RESEARCH ARTICLE Open Access

Self-reported patterns of impairments

in mentalization, attachment, and
psychopathology among clinically referred
adolescents with and without borderline
personality pathology
Sune Bo1,2* and Mickey Kongerslev3,4

Abstract
Background: Previous research, which primarily focused on adult samples, suggests that individuals with borderline
personality disorder (BPD) display high levels of psychopathology, dysfunctional mentalization and problematic
attachment to others. The current study investigated whether impairments in mentalization, attachment, and
psychopathology are more severe in outpatient adolescents with BPD than in a clinical comparison group.
Methods: Consecutive referrals to a child and adolescent psychiatric clinic were clinically assessed with a battery
of self-report instruments to assess mentalization, attachment, and psychopathology. Specifically, in regard to BPD a
self-report questionnaire was employed to decide if patients were classified into the BPD or the clinical comparison
group. The main outcome variables of adolescents with a primary diagnosis of BPD were then compared with
those of a clinical comparison group comprising patients receiving psychiatric diagnoses other than BPD.
Results: Relative to the clinical group without BPD, and after controlling for sociodemographic variables, the BPD
group displayed poorer mentalizing abilities, more problematic attachments to parents and peers, and higher
self-reported levels of psychopathology.
Conclusions: The results of this study suggest that BPD is a severe mental condition in adolescents and is
characterized by poor mentalizing abilities, attachment problems and high levels of psychopathology compared
to adolescents with psychiatric disorders other than BPD. Hence, clinicians should consider BPD when conducting
diagnostic assessments, and evidence-based treatments for this vulnerable group should be developed.
Keywords: Borderline personality disorder, Personality disorder, Reflective functioning, Mentalization, Attachment,
Adolescence

Background Specifically, evidence suggests that adults with PD ex-

In adult populations, personality disorders (PDs) in hibit poorer social and interpersonal functioning, are
general and borderline personality disorder (BPD) in less likely to prospectively maintain an occupation,
particular are related to significant impairments in gen- and report less life-satisfaction compared to people
eral functioning when compared to subjects without PD without PD [2–4]. Regarding adolescents, longitudinal
diagnoses and those with other mental disorders [1]. studies show that early maladaptive and pathological
personality features predict later social and functional
impairments (i.e., failure to complete school, alcohol
* Correspondence: [email protected]
1
Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark and drug dependence, and hazardous and antisocial
2
Department of Child and Adolescent Psychiatry, Region Zealand Psychiatry, behaviors) [5–10].
Roskilde, Denmark
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Bo and Kongerslev Borderline Personality Disorder and Emotion Dysregulation (2017) 4:4 Page 2 of 10

Additionally, studies report a high prevalence of PDs child and his or her primary caregiver and is dependent
in both the general and clinical populations [11] and that upon a secure attachment relationship [31] in which the
these disorders are associated with excessive societal primary caregiver adequately mirrors the child’s mental
costs [12, 13]. The increasing attention given to and re- state. The mirroring process must be both contingent
search conducted in the field of PDs in adult populations (e.g., fear is mirrored with fear and not joy) and marked
has encouraged the development of new and specialized (e.g., the mental state being mirrored must be similar
treatments for adults with PDs, notably BPD, in the last but clearly different from that of the caregiver). Thus, a
two decades [14]. secure attachment relationship in which the caregiver
Historically, however, less attention has been given to benignly and accurately represents the child as an
PDs in childhood and adolescence [15]. Until recently, intentional agent with intentions, thoughts, and emo-
many clinicians and researchers did not acknowledge tions underpins the development of the capacity to men-
the existence of personality pathologies in adolescents talize and secure the normative development of the
[16–18]. Indeed, they did so despite the fact that, ac- child’s personality [34].
cording to the Diagnostic and Statistical Manual of In contrast, the pathological trajectory leading to BPD
Mental Disorders, Fifth Edition (DSM-5) and its pre- is characterized by a caregiver who is unable to provide
decessors, PD diagnoses may be applied to adoles- a secure attachment relationship, specifically defined by
cents when the individual’s particular maladaptive inadequate mirroring (i.e., un-marked and non-
personality traits appear to be pervasive and persist- contingent; see [34] for details). In this case, because the
ent, are unlikely to be limited to a particular develop- caregiver is unable to mirror and represent the mind of
mental state or to another mental disorder, and are the child, the child will display difficulties in understand-
present for 1 year or more [19]. ing how actions and mental states are linked in the self
Indeed, the available research suggests that PDs in ad- and others [31]. In the mentalizing theory, the difficul-
olescents younger than 18 years can be diagnosed as re- ties pertaining to insecure attachment relations and dys-
liably and with as much validity as in adulthood and that functional mentalizing, as explained above, are specifically
the prevalence of PDs in adolescents in both the general believed to underlie BPD. This does not mean that BPD is
population and clinical settings are comparable to those the only psychiatric disorder characterized by dysfunc-
reported for adults [15, 17, 20, 21]. Developmental re- tional mentalization and insecure attachment [31].
search suggests that PDs are moderately stable during However, the mentalizing theory emphasizes these charac-
adolescence [22] and are strongly related to childhood teristics in particular as underlying BPD. Problematic at-
emotional difficulties and problematic behavior [23–25]. tachment relations and dysfunctional mentalization have
Furthermore, studies have indicated that delays in the also been found in empirical studies in adolescents with
diagnosis of PDs and the provision of interventions in BPD [35–38]. Recent empirical findings showed that prob-
adolescence can potentially result in devastating conse- lematic family functioning and low maternal care were
quences and poor long-term prognoses [26–28]. predictors of BPD in adolescents [39], underscoring the
Most theoretical and empirical developmental models role of attachment relationships between parents and chil-
of BPD either implicitly or explicitly assume that attach- dren in the development of BPD in adolescents. Another
ment problems or interpersonal trauma and difficulties recent study, displayed how BPD patients compared to
are related to the later development of BPD. According non-BPD psychiatric controls and healthy controls,
to the mentalization-based model of BPD, the core path- showed more dysfunctional emotion regulation, even
ology underlying BPD is associated with dysfunction in when controlling for important sociodemographic and
mentalization and insecure attachment patterns [29]. clinical variables [40]. In a community-dwelling study with
Mentalization refers to the ability to understand the self Italian adolescents, findings showed that non-suicidal self-
and others as intentional agents with minds [30]. Menta- injury (NSSI) and emotional dysregulation are moderately
lizing is considered important for interpersonal function- related to BPD features in adolescents [41]. This finding
ing because it enables people to understand behavior in was replicated by Kaees and colleagues [42] in adolescent
terms of mental states in regard to both the self and inpatients with NSSI and suicide attempts (SA) and
others [31]. Research has demonstrated that dysfunc- showed that dimensional borderline pathology was associ-
tions in mentalization are a core feature in patients with ated with NSSI and SA. In line with recent developmental
BPD [32], and based on many studies that link BPD and theories explaining BPD (i.e., mentalisation-based theory),
mentalizing dysfunctions, promising theories have been Sharp and colleagues [43] found that specifically hyper-
proposed that apply the mentalization-based model to mentalizing (i.e., ascribing intentions and beliefs to people
explain the emergence of BPD in adolescents [33]. The where non is) mediated the relationship between attach-
mentalizing theory suggests that the capacity to menta- ment coherence and borderline pathology. In another
lize is developed via the close relationship between a study Ramos and colleagues [44] found, in a sample of 60
Bo and Kongerslev Borderline Personality Disorder and Emotion Dysregulation (2017) 4:4 Page 3 of 10

adolescents BPD patients, that attachment anxiety was focuses on handling adolescents, including those with
positively related to internalizing psychopathology but PDs. This clinic specializes in the assessment and treat-
negatively related to externalizing pathology. Furthermore, ment of a broad range of mental health disorders in
in a study examining the trajectories of borderline path- referred children aged 0 to 17 years in Region Zealand.
ology and psychosocial functioning, results indicated that Within this clinic, the team involved in this study specific-
the development of BPD was significantly related to wors- ally handles adolescents aged 13–18 years. Social author-
ening in academic, social and mental health outcomes ities, general medical practitioners, psychiatrists, and
[45]. Finally, in a recent systematic review and meta- school services can refer adolescents to this clinic. The
analysis, Winsper and colleagues [46] found that BPD in staff at the clinic consists of experienced and qualified spe-
adolescents is related to the same aetiological and psycho- cialized psychiatrists, nurses, and clinical psychologists.
pathological issues as those found in adults with BPD.
Despite emerging theories on BPD in adolescents and Participants and procedure
research findings pointing to psychological dysfunctions All consecutive referrals to the team that focuses on ad-
in BPD, there still exist gabs in the research literature on olescents within the child and adolescent psychiatric
BPD in adolescents. First, a variety of different clinical clinic from 2013 to 2015 were approached to participate
variables have been identified as pertaining to BPD, but in the study. Inclusion criteria were age between 13 and
rarely have they been investigated in the same study. 18 years and Danish as the first language. In the BPD
Second, many studies have compared BPD groups to group, we only included patients with a BPD diagnosis
healthy controls but few have included a clinical non- as defined by a score of 66 or above on the Borderline
BPD comparison group. Third, and specifically related Personality Feature Scale for Children (BPFS-C) [38].
to attachment, no studies have explored the quality of The remaining patients (i.e., those not who did not re-
self-reported attachment in relation to both parents and ceive a PD diagnosis) were included in the clinical com-
peers in patients with and without BPD. Finally, and to parison group.
the authors’ knowledge, no studies have been conducted All patients were seen at intake by at least two mem-
as a naturalistic clinical comparison study in an ordinary bers of the staff for clinical and diagnostic assessments.
child and adolescents’ psychiatric clinic, adding eco- These assessments also included interviews with family
logical validity to the findings. Hence, to the best of our members and the collection of information from schools
knowledge, no studies have explored the differences be- and social workers. The patients’ final clinical diagnoses
tween patients with and without borderline pathology in were decided at weekly clinical conferences attended by
terms of attachment, mentalizing and psychopathology both psychologists and child and adolescents psychia-
in a sample of adolescent psychiatric patients. trists. As a part of this study, all patients also filled out a
Thus, the aim of this study was to explore the patterns battery of self-report questionnaires measuring border-
of impairment in an outpatient adolescent clinical sample line features, attachment, mentalization, externalizing
diagnosed with BPD compared to those of a clinical group and internalizing pathologies, self-harm and risk taking
without PD but with other mental disorders. Specifically, behaviors, and depression. These self-report question-
we wanted to determine whether there was a difference naires were administered within 2 weeks of the referral
between BPD and clinical comparison subjects with re- and were filled out by the adolescents before they knew
spect to attachment to peers and parents and mentaliza- which diagnosis they would receive at the clinic. The
tion. We also examined differences regarding the severity clinic staff was kept blinded to the data from the ques-
of psychopathology, self-harm and risk-taking behaviors, tionnaires until after the final decisions regarding the
and depression. We hypothesized that the BPD group diagnoses were made. As no semi-structured PD inter-
would display more problematic attachment relations, view was systematically administered to all patients,
more mentalizing dysfunctions, a significantly higher level BPD diagnoses was decided based on the total score on
of psychopathology, more depressive features and more the BPFS-C (see below). The total sample comprised
self-harm and risk-taking behaviours than the group with- 109 patients, 45 of whom received a diagnosis of BPD
out BPD. We also predicted that significant differences with reference to the BPFS-C. In the clinical comparison
would be apparent from both the dimensional (number of group, 25 participants were diagnosed with depression,
borderline features) and categorical (meeting the criteria 11 with attention-deficit/hyperactivity disorder (ADHD),
for a BPD diagnosis) perspectives. 9 with anxiety disorders, 9 with other mixed disorders of
conduct and emotions, 5 with pervasive developmental
Methods disorder, and 5 with conduct disorder. Nine patients
Setting were excluded because they were diagnosed with PDs
This study was conducted at a Danish outpatient child other than BPD, and 17 of the referred patients never
and adolescent psychiatric clinic by a team that specifically showed up to the initial clinical evaluation or moved
Bo and Kongerslev Borderline Personality Disorder and Emotion Dysregulation (2017) 4:4 Page 4 of 10

during the assessment periode. Information on the colleagues [49] found that the optimal cut-off score for
sociodemographic characteristics of the total sample and discriminating BPD among adolescent inpatients using
stratified by groups is presented in Table 1. the BPFS-C was 66. The area under the curve (AUC)
was .931, indicating high accuracy of the BPFS-C in-
Measures strument in regard to the gold standard semi-
BPFS-C [38] structured interview. The BPFS-C was included in the
The BPFS-C assesses borderline personality traits di- present study to assess borderline pathology both cat-
mensionally and was adapted from the Borderline Scale egorically and dimensionally. In the current study,
of the Personality Assessment Inventory (PAI; [47]) for Cronbach’s α was 0.90.
use with children and adolescents. This scale is com-
posed of 24 items, which are summed to yield a total Youth self-report (YSR) [50]
score after four of the items are reverse scored. Each The YSR is a widely used questionnaire that measures a
item is scored on a five-point Likert scale ranging from broad range of psychopathologies in young people aged 11
1 (not at all true) to 5 (always true). Higher scores indi- to 18 years. It includes 112 problem items, each of which
cate greater levels of borderline personality features. can be rated 0 (not true), 1 (somewhat or sometimes true)
Crick and colleagues [38] demonstrated high internal or 2 (very true or often true). The YSR has shown excellent
consistency and established evidence of the scale’s con- psychometric properties and good correspondence with
struct validity. Sharp and colleagues provide further evi- specific DSM diagnostic categories [51, 52]. In the present
dence supporting its criterion validity, cross-informant study, we used the two broad subscales of Internalizing
concordance, and concurrent validity [48]. Chang and and Externalizing Psychopathologies. The Internalizing

Table 1 Sociodemographic characteristics of the total sample and by groups

Sociodemographic characteristics Total sample Borderline personality disorder group Clinical comparison group
(N = 109) (n = 47) (n = 62)
Age (Mean ± SD) 16.1 ± 1.1 15.9 ± 1.2 16.2 ± 1.1
Range in years 13–18 13–18 13–18
Gender
Male 44 (40.4%) 14 (29.8%) 27 (43.5%)
Female 65 (59.6%) 33 (70.2%) 35 (56.5%)
Educational level
Primary School 55 (50.5%) 28 (59.6%) 27 (43.5%)
High School 18 (16.5%) 4 (8.5%) 14 (22.6%)
Youth education 14 (12.8%) 3 (6.4%) 11 (17.7%)
None 22 (20.2%) 12 (25.5%) 10 (16.1%)
Upbringing
Both parents 59 (54.1%) 24 (51.1%) 35 (56.5%)
Mother 44 (40.4%) 19 (40.4%) 25 (40.3%)
Father 2 (1.8%) 2 (4.3%) 0 (0%)
Fostercare 4 (3.7%) 2 (4.3%) 2 (3.2%)
Current living arrangements
Parents 89 (81.7%) 37 (78.7%) 52 (83.9%)
Appartment 2 (1.8%) 2 (4.3%) 0 (0%)
Fostercare 18 (16.5%) 8 (17.0%) 10 (16.1%)
Civil Status
Single 77 (61.5%) 29 (61.7%) 38 (61.3%)
In a relationship 42 (38.5%) 18 (38.3%) 24 (38.7%)
Job-status (beside school)
In a job 31 (38.4%) 12 (25.5%) 19 (30.6%)
Not in a job 78 (71.6%) 35 (74.5%) 43 (69.4%)
Bo and Kongerslev Borderline Personality Disorder and Emotion Dysregulation (2017) 4:4 Page 5 of 10

scale is composed of the Anxious/Depressed, Withdrawn/ Statistical analysis

Depressed, and Somatic Complaints scales, whereas the SPSS version 23 for MAC was used to conduct all of the
Externalizing scale includes two subscales: Aggressive statistical analyses. Prior to testing the hypothesis, we
Behavior and Rule-breaking Behavior. The Cronbach’s α in performed preliminary analyses to determine the means,
this study was 0.95. standard deviations and ranges for all variables included
in the study. Then, independent t-tests were conducted
Beck depression inventory for youth (BDI-Y) [53] to identify significant differences between the BPD group
The BDI-Y is used to assess depressive features in chil- and the clinical comparison group in attachment (IPPA-
dren and adolescents aged 7 to 18 years old. This test Peer and IPPA-Parent), mentalization (RFQ:YV), border-
consists of 20 questions about depressive symptomatol- line pathology (BPFS-C), depression (BDI-Y), self-harm
ogy within the past 14 days, each of which is rated from and risk-taking behaviors (RTSHIA), and internalizing
0 (never) to 3 (always). The BDI-Y is widely used and and externalizing pathologies (YSR-internalizing and
has demonstrated adequate psychometric properties YSR-externalizing scales). Next, Pearson correlational
[54]. In the current study, Cronbach’s α was 0.94. analysis was used to explore the bivariate relationships
between all variables in the study and to elucidate the di-
Risk-taking and self-harm inventory for adolescents mensional relationship between borderline pathology
(RTSHI-A) [55] and attachment and mentalization. Finally, we con-
The RTSHI-A is composed of 38 items adapted from the ducted a multivariate analysis of covariance (MAN-
adult Self Harm Inventory (SHI, [56]) and is used to as- COVA); the grouping variable was BPD versus clinical
sess risk-taking and self-harming behaviors in children comparison subjects without BPD, and the dependent
and adolescents. This measure requires the adolescent variables were attachment (IPPA-Peer and IPPA-Parent),
to rate the frequency with which he or she has engaged mentalization (RFQ:YV), borderline pathology (BPFS-C),
in self-harm or risk-taking behaviors using a four-point depression (BDI-Y), self-harm and risk-taking behaviors
Likert scale. The RTSHI has been shown to have accept- (RTSHIA), and internalizing and externalizing patholo-
able psychometric properties [55]. Cronbach’s alpha in gies (YSR-internalizing and YSR-externalizing scales).
this study was 0.88. The MANCOVA analysis was followed by a separate
analysis of variance (ANOVA) for each dependent vari-
Inventory of parent and peer attachment - revised (IPPA-R) able [60]. The datasets analyzed in the current study are
[57] available from the corresponding author upon request.
The IPPA-R is a reliable and valid 53-item self-report
questionnaire that measures attachment in adolescence. Results
This instrument is composed of two scales that measure Table 2 shows that the independent t-test revealed sig-
attachment to parents and peers. For each of the 28 nificant differences between the BPD and clinical com-
items assessing parent attachment and 25 items asses- parison group for all variables. Thus, relative to the
sing peer attachment, respondents are required to rate clinical comparison group, the BPD group displayed
the degree to which each item is true for them on a five- higher levels of self-reported BPD features, internalizing
point scale that ranges from ‘Almost always or always and externalizing psychopathologies, depressive symp-
true’ to ‘Almost never or never true’. Higher scale scores tomatology, impulsivity and self-harm and poorer men-
indicate more problematic attachment relations to par- talizing capacity and attachment to parents and peers.
ents and peers. In this study, Cronbach’s α = 0.91. When examining the borderline pathology dimensionally,
we found the same pattern. The bivariate correlations in-
Reflective function questionnaire for youth (RFQY) [58] dicate that more borderline pathology is correlated with
The RFQY is a 46-item self-report questionnaire de- increased dysfunctional mentalization, problematic attach-
signed to measure the general capacity for reflective ment relations to both parents and peers, and psychopath-
function or mentalizing. Each item is rated on a 6-point ology, including depression and self-harm (see Table 3).
Likert scale ranging from Strongly Disagree to Strongly
Agree. A total scale score can be derived by summing Clinical differences between the BPD and clinical
the individual item scores. High total scores indicate comparison groups
higher capacities for mentalizing. The RFQY demon- MANCOVA was used to test for differences between the
strated good psychometric properties, including con- BPD and clinical comparison groups in attachment,
struct validity, in a recent psychometric study [59]. mentalization, borderline features, externalizing and in-
Cronbach’s alpha in the current study was 0.88. ternalizing pathologies, depression, impulsivity and self-
Danish-translated versions of these instruments were harm while controlling for age, gender, educational level,
used in this study. and living status. According to the Pillai’s trace test, the
Bo and Kongerslev Borderline Personality Disorder and Emotion Dysregulation (2017) 4:4 Page 6 of 10

Table 2 Comparison of clinical characteristics among patient groups

Clinical Measures All (N = 109) Borderline Personality disorder group (n = 47) Clinical comparison group (n = 62)
Mean (SD)/% Mean (SD) Mean (SD)
BPDFS-C (score) 69.7 (16.8) 86.6 (9.6)* 56.8 (6.8)*
YSR: Externalizing 22.0 (10.5) 29.1 (8.0)* 16.6 (8.8)*
*
YSR: Internalizing 29.5 (12.3) 38.8 (8.3) 22.5 (10.0)*
RFQY 8.2 (1.3) 7.2 (1.0)* 9.0 (0.9)*
*
BDI-Y 49.2 (11.9) 56.8 (9.8) 43.4 (9.6)*
IPPA-Peer 47.4 (8.5) 54.6 (4.2)* 42.2 (7.0)*
*
IPPA-Parent 54.3 (9.6) 59.2 (7.6) 50.3 (9.6)*
RTSHIA 59.4 (15.3) 66.7 (14.7)* 53.8 (13.4)*
Note. BPFS-C The Borderline Personality Features Scale for Children, YSR The Youth Self-Report, RFQ-Y Reflective Function Questionnaire for Youth, IPPA inventory
of parent and peer attachment, RTSHI risk-taking and self-harm inventory, BDI-Y Beck Depression Inventory for Youth
*
Statistically significant difference between the borderline personality disorder group versus clinical comparison group, p < .001

results revealed significant differences between the BPD to parents and peers, and higher levels of risk-taking
and clinical comparison groups: V = 0.80, F(8,96) = 48.1, behaviors, self-harm, depressive symptomatology, and
p < 0.001 (Table 4). Note that none of the covariates internalizing and externalizing psychopathologies. When
were significantly related to BPD. Box’s M indicated that exploring the differences between groups, using the opti-
the assumption of equality of covariance matrices for the mal cut-off for the BPFS-C (a total score of 66 or above)
MANCOVA was not violated (p = 0.06). to categorize patients into the BPD or clinical com-
As shown in Table 5, separate univariate ANCOVAs parison group, we found the same results. In the BPD
performed for the outcome variables revealed a significant group, we observed significantly more mentalizing
effect between the BPD and clinical comparison groups dysfunctions, more problematic attachment relations
on all variables. Thus, significant differences between the to both peers and parents, and more severe levels of
two groups were found for attachment, mentalizing abil- psychopathology, including depression and a greater
ities, borderline features, depressive symptomatology, propensity for self-harm.
externalizing and internalizing pathologies, risk-taking Taken together, these findings suggest that adolescents
behavior and self-harm. diagnosed with BPD face a wide range of severe and
complex impairments in their mentalizing abilities,
Discussion difficulties with attachment, and high levels of both
In this study, we explored the differences in mentaliza- internalizing and externalizing psychopathologies. Thus,
tion, attachment, and psychopathology between adoles- in adolescents, BPD is a severe disorder that is associ-
cents with BPD and clinical comparison subjects both ated with both poor psychological well-being and high
dimensionally and categorically. As predicted, more se- treatment needs. The finding that participants diagnosed
vere borderline pathologies were correlated with poorer with BPD display high levels of both internalizing and
mentalizing abilities, problematic attachment relations externalizing psychopathologies has also been observed

Table 3 Bivariate correlations between main study variables

Variables BPFS-C Total RFQ-Y IPPA-Parent IPPA-Peer YSR Total YSR-Externalising YSR-Internalising BDI-Y
BPFS-C Total 1.00
RFQ-Y -.72** [−.80, −.62] 1.00
IPPA-Parent .50** [.37, .62] -.38**[−.51, −.22] 1.00
IPPA-Peer **
.65 [.54, .75] -.58 [−.45, −.75]
**
.38**[.22, .54] 1.00
YSR Total **
.83 [.79, .88] -.75 [−.81, −.67]
**
.54** [.40, .65] .66** [.56, .76] 1.00
YSR-Externalising **
.68 [.55, .80] -.65 [−.74, −.54]
** **
.44 [.24, .61] **
.48 [.33, .63] .80** [.72, .86] 1.00
YSR-Internalising **
.73 [.64, .81] -.63 [−.71, −.53]
** **
.48 [.31, .61] **
.60 [.48, .70] .85** [.78, .90] .43** [.24, .61] 1.00
BDI-Y **
.63 [.48, .75] -.53 [−.66, −.37]
** **
.46 [.29, .61] **
.58 [.44, .71] **
.71 [.56, .81] **
.39 [.19, .58] .79** [.69, .86] 1.00
Note: BPFS-C The Borderline Personality Features Scale for Children, YSR The Youth Self-Report, RFQ-Y Reflective Function Questionnaire for Youth, IPPA inventory
of parent and peer attachment, RTSHI risk-taking and self-harm inventory, BDI-Y Beck Depression Inventory for Youth
Bias corrected and accelerated bootstrap 95% CIs are reported in square brackets
Bo and Kongerslev Borderline Personality Disorder and Emotion Dysregulation (2017) 4:4 Page 7 of 10

Table 4 MANCOVA analysis of BPD versus clinical comparison Regarding BPD in adolescents, theories suggest that
subjects as a function of attachment, mentalizing, borderline incapacities in mentalizing functioning are specifically
features, emotional dysregulation, externalizing and internalizing characterized by a tendency to over-attribute intentions,
pathology, depression and risk taking and self-harm after beliefs, and wishes to people in situations where there is
controlling for sociodemographic variables no proof supporting such attributions [33]. This form of
MANOCOVA Test: Multivariate test dysfunctional mentalizing is termed hypermentalizing
Effect Pillai’s trace V F df p and can potentially cause substantial interpersonal diffi-
Intercept 0.68 23.41 8 0.001 culties [29]. The over-attribution of intentions to other
Age 0.08 1.04 8 0.41 people in social situations can easily lead to misunder-
Gender 0.05 0.58 8 0.80 standings that can cause conflicts and problematic rela-
tionships. If left out of social interpersonal relationships,
Educational Level 0.11 1.52 8 0.16
the adolescent can then become isolated from the valu-
Living status 0.10 1.31 8 0.25
able social and cultural knowledge (epistemic isolation)
Grouping variable (BPD 0.80 48.14 8 0.001 necessary for normative development [31]. The results
vs. clinical comparisons)
of this study do not specifically indicate a hypermen-
talizing profile for the BPD group because we were
unable to detect such dysfunctions using the instru-
in a large population-based sample of adults in the US ments included in this work. However, the results are
[61] and in hospitalized adolescents [62]. Indeed, com- in line with the general mentalization-based theory of
plex co-occurrence across the spectra of internalizing BPD, which identifies profound mentalizing dysfunc-
and externalizing psychopathologies appears to be a tions as especially characteristic for and underlying
fairly characteristic feature of BPD in adolescence and BPD symptomatology [64].
adulthood and may indicate of a common susceptibility Another noteworthy finding was the differential dis-
to distress, mental pain, and externalization [61, 63]. criminative abilities between the BPD and clinical con-
The results reflecting dysfunctional mentalization and trol groups in terms of parental and peer attachments.
problematic attachment relations in the BPD group are Although the empirical literature generally shows evi-
in good agreement with the mentalization-based model dence that supports links between attachment difficulties
for BPD [31] and empirical findings showing that the and concurrent and prospective associations with psy-
core pathology of BPD in adolescents is related to chopathology and BPD, there is a paucity of data on the
dysfunctional mentalization and problematic attachment potential differential effects of parent versus peer attach-
relations [29, 32, 33, 35, 36]. Thus, the findings of this ment problems on the development of psychopathology
study support the hypothesis that problematic attachment in general and BPD specifically [65, 66]. Additionally,
relations to both parents and peers and dysfunctional this result appears to be consistent with both diagnostic
mentalization may be core features in the understanding classifications and theoretical approaches, including em-
and development of BPD [36]. pirical research, that highlight pervasive interpersonal

Table 5 ANCOVA analysis of group differences between the borderline and clinical comparison subjects as a function of
attachment, mentalizing, internalizing and externalizing psychopathology, depression, borderline features, and impulsivity and
self-harm
ANCOVA test: Test of Between-subjects Effect
Dependent variable Type III Sum of Squares df F p
RTSHIA (impulsivity and self-harm) 3942.3 5 20.6 0.001
BDI-Y (depression) 4256.6 5 45.7 0.001
RFQ-Y (mentalizing) 81.7 5 83.8 0.001
YSR-internalizing (internalizing pathology) 6609.3 5 77.0 0.001
YSR-externalizing (externalizing pathology) 3511.5 5 51.8 0.001
IPPA-Peer (attachment to peers) 3690.4 5 98.7 0.001
IPPA-Parent (attachment to parents) 1739.7 5 22.8 0.001
BPFS-C (Borderline features) 22549.0 5 337.9 0.001
Note: BPFS-C The Borderline Personality Features Scale for Children, YSR The Youth Self-Report, RFQ-Y reflective function questionnaire for youth, IPPA inventory of
parent and peer attachment, RTSHI risk-taking and self-harm inventory, BDI-Y Beck Depression Inventory for Youth
Bo and Kongerslev Borderline Personality Disorder and Emotion Dysregulation (2017) 4:4 Page 8 of 10

difficulties and dysfunctions as core features of PDs, in- mentalizing abilities and interpersonal dysfunctions may
cluding BPD [67–70]. Thus, this study indicates that be important treatment targets in addition to the more
BPD in adolescents is related to substantial attachment behavioral manifestations of the BPD syndrome, such as
problems regarding both parents and peers relative to a self-harm. Fortunately, new and promising psychosocial
clinical comparison group. These findings suggest that treatments targeting BPD in adolescents are being devel-
adolescents with BPD face great potential risks regarding oped and will hopefully become more broadly available
their normative developmental processes [31, 64] be- to these vulnerable young people and their families in
cause these individuals must struggle to establish the the near future [16, 35, 72–74]. The clinical recognition
stable relationships with both parents and peers that are of BPD and the availability of evidence-based treatments
necessary for healthy development. for this debilitating disorder are both crucial to our
ability to help these young people and their families.
Limitations
This study has several limitations. First, the diagnostic Abbreviations
ADHD: Attention deficit hyperactivity disorder; ANCOVA: Analysis of
assessments were based on clinical interviews, and sys- covariance; BDI-Y: Beck depression inventory for youth; BPD: Borderline
tematic standardized and structured clinical instruments personality disorder; BPFS-C: Borderline personality features scale for children;
were not always used. This diagnostic procedure is subject CCG: Clinical comparison group; DSM: Diagnostic and statistical manual of
mental disorders; IPPA-R: Inventory of Parent and Peer Attachment – Revised;
to a range of psychometric issues, including a high risk of MANCOVA: Multivariate analysis of covariance; PD: Personality Disorder;
overlooking psychopathology and poor inter-rater reliabil- RFQY: Reflective function questionnaire for youth; RTSHI-A: Risk-Taking and
ity [71]. Additionally, most of the variables of interest in self-harm inventory for adolescents; SPSS: Statistical program software
package; YSR: Youth self-report
this study were self-reported, and self-reporting is known
to be subject to many potential psychometric issues, such Acknowledgements
as biased responding. For this reason, future studies None.
should include other types of measures and measurement
Funding
methods when further investigating dysfunction and No funding was provided for this study.
psychopathology in BPD.
Another limitation relates to the cross-sectional nature Availability of data and materials
of the study design, which does not allow for inferences The datasets analyzed in the current study are available from the
corresponding author upon reasonable request.
about causal relationships and issues relating to the longi-
tudinal relationships between variables. This issue should Authors’ contributions
be addressed in future studies. Furthermore, whether our SB designed the study, collected the data, analyzed the data, and wrote and
results are generalizable to populations with more or less revised the paper. MK contributed to the study design, data analyses, and
literature review; wrote sections of the paper; and contributed to the
severe levels of pathology, such as outpatients or commu- revisions. Both of these authors read and approved the final manuscript.
nity samples, is unknown. Finally, the small sample size
did not allow us to robustly test the potential effects of Competing interests
The authors declare that they have no competing interests.
gender or age.
Consent for publication
Conclusions The manuscript contains no individual data (video or images).
Despite the aforementioned limitations, our study high-
lights that, in a clinical sample of adolescents, BPD is Ethics approval and consent to participate
Permission to use data from patients’ journals was obtained by the Danish
associated with significantly more severe self-reported Health Authority (3-3013-1540/1/); hence, no written consent or ethical
mentalization dysfunctions, attachment problems and approval of the project was necessary.
psychopathology relative to a clinical comparison group
Author details
without BPD. The results also suggested that poor men- 1
Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark.
talizing abilities and problematic attachments to peers 2
Department of Child and Adolescent Psychiatry, Region Zealand Psychiatry,
and parents characterized the BPD group compared to Roskilde, Denmark. 3Centre of Excellence on Personality Disorder, Region
Zealand Psychiatry, Slagelse, Denmark. 4Department of Psychology, University
the clinical comparison group. This finding is in line of Southern Denmark, Odense, Denmark.
with the recently developed mentalization-based theory
for BPD. The potentially differential role of attachment Received: 3 September 2016 Accepted: 9 February 2017
to peers in adolescents with BPD compared to attach-
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