Anna Freud Centre

Anna Freud Centre

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DO NOT CIRCULATE WITHOUT THE AUTHOR’S PERMISSION

THE ANNA FREUD CENTRE

50THANNIVERSARY

LONDON

24THINTERNATIONAL SCIENCTIFIC COLLOQUIUM

CREATING CONNECTIONS:

PYSHCO-ANALYSIS, NEUROSCIENCE AND DEVELOPMENT

NOVEMBER 2, 2002

A DEVELOPMENTAL NEURO-PSYCHOANALYTIC REAPPRAISAL

OF ANNA FREUD’S STUDIES OF BORDERLINE CHILDREN

ALLAN N. SCHORE

UNIVERSITY OF CALIFORNIA AT LOS ANGELES

SCHOOL OF MEDICINE

In 1969 Anna Freud published “The assessment of borderline cases,” in which she formally applied her groundbreaking developmental psychoanalytic perspective to the etiology of children who develop clinical states on the border of psychosis. The clinical presentation of these youngsters, she said, is marked by a failure to achieve the developmental attainments of intact object relations and an ego that is adequately defended against irruptions from the id. The deficits of such children are thus characteristic of an arrest on a preoedipal level of personality organization. This form of infantile psychopathology, frequently accompanied by psychosomtic symptomatology, is not caused by conflict, but by what Balint (1968) called “basic faults,” that is, deviations in development.

This work was an extension of earlier psychoanalytic pioneers in this area – Mahler’s studies of childhood psychosis (1949), Weil’s (1953) observations of severe disturbances of ego development, and Ekstein and Wallerstein’s (1954) research on the psychology of borderline and psychotic children. Advancing this work, Freud postulated that these children live on the border between a tenuous and fragile object cathexis and primary identification. That is, they show an impaired capacity for internalization, manifest in an inability to establish object constancy and self soothing, and an inefficient capacity to maintain cathexis of objects, expressed in increased clinging and dependence.

Even more speciifically, she proposed that borderline children exhibited massive developmental arrests, including an inability to be comforted by others, poor reality testing and synthetic functions, and inadequately developed defense mechanisms. This latter deficit is seen in a regresive tendency to retreat to more primitive forms of introjection on primitive psychotic levels. With respect to the failure to develop more complex defenses she notes, “It may well be that it is the dreaded confrontation with panic proper which accounts for the use of the most primitive of all defense mechanisms, namely, flight” (p. 200).

Aside from the details of the symptom presentation, and perhaps even more importantly, Freud presented her ideas on early borderline etiology in the context of an overarching developmental theory, one that spanned both normal and abnormal development. And herein lies perhaps her most important contribution – the theoretical construct of developmental lines, a perspective that lies at the base of modern conceptions of developmental psychopathology. In her ontogenetic model, developmental lines are a product of the interaction between drive and superego development and the individual’s reaction to environmental influences, that is “between maturation, adaptation, and structuralization”. She notes, “Far from being abstractions, developmental lines in the sense here used, are historical realities which, when assembled, convey a convincing picture of an individual child’s personal achievements or, on the other hand, of his failures in personality development” (A. Freud, 1965, pp. 63-64; in Meissner, 1984).

The matter of “structuralization” is at present equated with brain maturation, and is an intense focus of developmental neuroscience. In the latest models brain maturation involves a transaction between (a) genetically coded programs for the formation of structures and connections between structures and (b) environmental influences. This modern conception fits very nicely with Anna Freud’s (1965) conception that psychic structure results from successive interactions between the infant’s biologically and genetically determined maturational sequences on the one hand, and experiential and environmental influences on the other.

We now know that in early borderline histories, less than optimal early environmental experiences negatively impact structuralization, that is the development of evolving psychic structure. Although Anna Freud, like her father before her, was uncertain about the existence of single incident trauma (usually understood as sexual trauma) as a pathogenetic mechanism, she did write that “traumatic and other pathogenic events usually occur over extended periods” (p. 4). As I’ll discuss shortly, this conception is consonant with recent ideas about ambient, cumulative relational trauma, and how it inhibits the experience-dependent maturation of the brain. She alludes to the growth-inhibiting effects of trauma in her statement, “Psychoanalytic treatment of the immature has revealed the hazards which threaten mental health on the one hand from the direction of the environment via the early deprivations, frustrations, object losses, traumatic occurrences, and on the other hand from inside the mental apparatus” (p. 342). These events, she says, ultimately lead to the “patients’ failure to cope with these obstacles.”

Furthermore, the fact that traumatizing experiences occur so early in life, at a time when basic structuralization of the psyche is in the process of formation, accounts for the severe alteration of the developmental trajectory seen in borderline disorders. Indeed it differentiates early preoedipal from later forming oedipal disorders. She states:

We can thus differentiate between two types of infantile psychopathology. The one based on conflict is responsible for the anxiety states and the phobic, hysterical, and obsessional neuroses; the one based on developmental defects, for the psychosomatic symptomatology, the backwardness, the atypical and borderline states (p. 70).

She also observes that what is important is not only the abnormalities caused by the trauma, but also “the defects in the personality structure itself which are caused by the aforementioned developmental irregularities and failures”. Again, the deflection of the personality is the primary pathogenetic mechanism. In contemporary terms, the primary negative impact of early relational trauma is the devastating effects it has on developing character structure and adaptive functions.

Anna Freud’s seminal speculations on the childhood borderline syndrome were subsequently taken up by child clinicians, theoreticians, and researchers. Pine (1974) described how these children suffer from severe developmental failure, expressed in disturbed ego function and object relationships. He cited various features of this childhood personality organization, including shifting levels of ego organization characterized by rapid regression and affective withdrawal, incomplete internalization of the caregiver, ego limitations expressed in social inhibition, shallow affect, sharp constriction of affective life, and emotional distance in human relationships, and internal disorganization, expressed as aggression in response to external disorganizers such as parental abuse and neglect.

In later writings Pine (1986) speculated that these children have early appearing constitutional defects that underlie the difficulties in social interactions and coping with stressors. Freud’s structuralization defects were now defined as neuropsychological defects. Pine suggested that the neurobiological impairments, coupled with trauma, are responsible for the child becoming overwhelmed by environmental stimuli, thereby precluding ongoing development. At the same time Paula Kernberg also associated the disorder with “minimal brain dysfunction.”

In very recent psychiatric studies, a number of workers are now confirming the presence of early abuse and neglect and neuropsychological deficits in this clinical population. Indeed, the etiology of borderline pathology in childhood is currently understood to depend upon diatheses (constitutional predisposition) and stressors. Diatheses are now identified through neurobiological and neuropsychological markers, including deficits in frontal lobe functions, and stressors are childhood trauma and parental psychopathology. The latter environmental risks are thought to combine with neurobiological vulnerabilities to shape the clinical syndrome (Zelkowitz). It has been observed that although sexual abuse is a weak predictor, a history of neglectful and traumatic experiences co-occurs in these patients (Zanarini). The neuropsychological vulnerabilities are thought to account for cognitive limitations that negatively affect the child’s ability to integrate the traumatic experience, and interfere with the resilience mechanism that can cope with the traumatic environment.

In the very latest models, it has been suggested that the neuropsychological abnormalities of borderline children are indeed, the result of environmental stresors, specifically reflecting the effects of neonatal stress on brain development (Graham). Due to the fact that the deficits appear in the emotional, social, and cognitive domains, the borderline pathology of childhood is now described as a “multiple complex developmental disorder.” The diagnostic criteria include deficts in three areas: dysregulation of affective state (panic episodes, terror, behavioral disorganization and regression, emotional variability), impairments in social behavior (disturbed attachment, detachment, avoidance, profound limitations in empathy), and impaired cognitive processing (Towbin). In a recent review in the Journal of the American Academy of Child and Adolescent Psychiatry, the authors, who cite Anna Freud’s seminal work, conclude, “we are thus no longer debating the existence of “the syndrome,” but the nosology” (Ad-Dab’Bagh & Greenfield, 2001, p. 961). I’m sure she would be pleased.

With this introduction in mind, in the remainder of this talk I’d like to present some very recent data that arise from the ongoing connections between psychoanalyis, neuroscience, and development that can deepen our understanding of the etiolology of borderline pathology of childhood, first outlined by Anna Freud. This material will appear in my 2 upcoming books Affect Dysregulation and Disorders of the Self, and Affect Regulation and the Repair of the Self, and a chapter, “The biological substrate of the human unconscious: The early development of the right brain and its role in emotional development,” in a volume soon to be published by the Anna Freud Centre.

Early relational trauma and borderline pathology of childhood

Let me begin with the problem of childhood trauma. In his recent writings Otto Kernberg now asserts:

The most important cause of severe personality disorders is severe chronic traumatic experiences, such as physical or sexual abuse, severe deprivation of love, severe neglect, unavailable parental objects as familial dispositions that can lead to the development of personality disorders (Kernberg, 1988).

Indeed, a large body of clinical research demonstrates that early trauma and abuse and disrupted attachments are frequent occurrences in the histories of children and adults diagnosed as borderline personality disorder. A study of published in the American Journal of Psychiatry reports that 91% of borderline patients report childhood abuse, and 92% report some type of childhood neglect (Zanarini). In an overview of the literature Paris summarizes the developmetal data and asserts “the weight of the research evidence supports the hypothesis that abuse during childhood is an important risk factor for borderline personality disorder.” This work is now moving away from sexual abuse to relational abuse.

Over the course of a number of recent works I have described the developmental psychoanalytic and neuropsychoanalytic aspects of relational trauma in infancy. The enduring detrimental effects of parent-inflicted trauma on the attachment bond is now well-established:

The continued survival of the child is felt to be at risk, because the actuality of the abuse jeopardizes (the) primary object bond and challenges the child’s capacity to trust and, therefore, to securely depend.

The two dominant forms of relational trauma are abuse, and the less studied yet even more pathogenic interpersonal stressor of ambient neglect. The abusive caregiver induces traumatic states of enduring negative affect in the child. Because her attachment is weak, she provides little protection against other potential abusers of the infant, such as the father. This caregiver is inaccessible and reacts to her infant's expressions of emotions and stress inappropriately and/or rejectingly, and therefore shows minimal or unpredictable participation in the various types of arousal regulating processes. Instead of modulating she induces extreme levels of stimulation and arousal, and because she provides no interactive repair the infant’s intense negative states last for long periods of time.

The impact of relational trauma on attachment is well documented, and these studies give important clues to the early histories of borderline personalities. Main and Solomon studied the attachment patterns of infant’s who had suffered trauma in the first year of life, “Type D”, an insecure-disorganized / disoriented pattern, one found in 80% of maltreated infants. In such cases the infant, instead of finding a haven of safety in the relationship, is alarmed by the parent. They note, “Because the attached infant inevitably seeks the parent when alarmed, any parental behavior that directly alarms an infant should place the infant in an irresolvable paradox in which it can neither approach, shift its attention, or flee”. The disorganization and disorientation is a “collapse” of behavioral and attentional strategies, and phenotypically resembles dissociative states (Hesse & Main, 2000; Main & Morgan, 1996). These infants are experiencing low stress tolerance, and at the most basic level, they are unable to generate a coherent behavioral coping strategy to deal with this interactive stress (Main & Solomon, 1989).

Main and Solomon documented the uniquely bizarre behaviors these 12-month-old infants show in Strange Situation observations. That these episodes of interruptions of organized behavior are often brief, frequently lasting only 10-30 seconds, yet they are highly significant. For example, they show a simultaneous display of contradictory behavior patterns, such as “backing” towards the parent rather than approaching face-to-face. Maltreated infants also show evidence of apprehension and confusion, as well as very rapid shifts of state:

One infant hunched her upper body and shoulders at hearing her mother’s call, then broke into extravagent laugh-like screeches with an excited forward movement. Her braying laughter became a cry and distress-face without a new intake of breath as the infant hunched forward. Then suddenly she (dissociated) became silent, blank and dazed.

Such behaviors generalize beyond just interactions with the mother. The intensity of the baby’s dysregulated affective state is often heightened when the infant is exposed to the added stress of an unfamiliar person. At a stranger’s entrance, two infants moved away from both mother and stranger to face the wall, and another “leaned forehead against the wall for several seconds, looking back in apparent terror”. These infants also exhibit “behavioral stilling” - that is, “dazed” behavior and depressed affect. One infant “became for a moment excessively still, staring into space as though completely out of contact with self, environment, and parent.” Another “fell face-down on the floor in a depressed posture prior to separation, stilling all body movements”.

Earlier I mentioned that relational trauma can take the form of abuse or neglect. The latter, the most sever form of maternal rejection, is a common aspect of clinical postnatal depression. Anna Freud obsereved

There is not one type of rejecting mother, there are many. There are those who are responsible for their rejecting attitude, who can be exhorted, advised, and helped toward a better adjustment to their children; there are also those for whom rejecting is beyond their control (1970, p. 378 – in Meissner, 1984, p. 409).

This latter description, of a physically close yet rejecting and emotionally unavailable mother and a disorganized infant is evocatively captured by Selma Fraiberg:

The mother had been grudgingly parented by relatives after her mother’s postpartum attempted suicide and had been sexually abused by her father and cousin. During a testing session, her baby begins to cry. It is a hoarse, eerie cry...On tape, we see the baby in the mother’s arms screaming hopelessly; she does not turn to her mother for comfort. The mother looks distant, self-absorbed. She makes an absent gesture to comfort the baby, then gives up. She looks away. The sceaming continues for five dreadful minutes. In the background we hear Mrs. Adelson’s voice, gently encoraging the mother. ‘What do you do to comfort Mary when she cries like this?’ (The mother) murmurs something inaudible...As we watched this tape later...we said to each other incredulously, ‘It’s as if this mother doesn’t hear her baby’s cries.

Ultimately, the child will transition out of heightened protest into detachment, and with the termination of the hopeless screaming, she’ll become, as Main and Solomon describe, silent, blank, and dazed.

Notice this latter context, although technically “interpersonal,” is more than rejecting, it is totally devoid of an mutually regulating interactions. Rather, both mother and infant, although in physical proximity, are simultaneousy autoregulating their stress in parallel but non-intersecting dissociative states. There is a void of subjectivity within each, and there is a void in the communications within the intersubjective field. There’s no dyadic attachment mechanism to convey or sense signals from the other. What stands out between them, both verbally and nonverbally, is this silent void, this vacuum, this black hole of nothingness. This regulatory failure is experienced as a dead spot in the infant's subjective experience. If this neglect becomes ambient, the effects on the infant are devastating. As Winnicott states (1960, p. 54), “If maternal care is not good enough, then the infant does not really come into existence, since there is no continuity in being.”