Fragile Selves: Working with Narcissistic and Borderline States of Mind

The link between early attachment style and personality disorder presentations

In this talk, Dr Diana Diamond describes the attachment style underlying borderline and narcissistic disorders. These have been identified over a randomized control trial of patients who exhibit either or both personality characteriztics. BPD is linked primarily to preoccupied and/or unresolved attachment and NPD with dismissing/or cannot classify attachment representations in which the individual oscillates between dismissing and preoccupied attachment strategies.

Diana Diamond’s case studies illustrate the connection between the early attachment bond and the adult’s behavior in therapy, distinguishing between the expression of BPD and NPD characteriztics in their internal representations and relationship behavior. In both groups, reflective functioning (RF) or the capacity to mentalize in attachment relationships is lacking, leading to difficulties with affect regulation. Because this deficit is compounded by negative expectations of others and/or self so these groups have traditionally been difficult to hold in therapy.

Dr. Diamond introduces the work of the Personality Disorders Institute in the Weill Medical College at Cornell University, where under the leadership of Otto Kernberg, M.D. and John Clarkin, Ph.D. they have developed a form of psychotherapy that is specifically focused on this group of patients, Transference Focussed Psychotherapy (TFP). This approach has been found to be remarkably effective, showing that after one year of treatment patients’ capacity to develop a coherent narrative, as measured by the Adult Attachment Interview, and for mentalization is greatly improved. She describes how.