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.The experience of safety within the context of a close emotional relationshipis essential for the development of an autonomous sense of self and anythingthat undermines the emergent self leads to anxiety and potentially an angryresponse as the child attempts to stabilize himself [7].Under conditions ofchronic neglect and insensitivity, instability of the self results first in angerand then aggression, which is evoked so frequently because of repeatedparental neglect that it becomes incorporated into the self-structure, withthe result that self-assertion, demand, wishes, needs have to be accom-panied by aggression if the self is to remain intact and stable.Suchdistortions to the self are not irreversible.The acquisition of the capacity tocreate a   narrative  of one s thoughts and feelings, to mentalize, can overcomeflaws in the organization of the self that can flow from the disorganization ofearly attachment.Thus the robustness of the self-structure is dependent onthe capacity to mentalize.Mentalizing depends substantially on optimal functioning of prefrontalcortex [8], a brain structure which has been linked to the regulation ofinterpersonal relationships, social co-operativity, moral behaviour andsocial aggression [9].The most favourable functioning of the prefrontalcortex in turn depends on optimal arousal, and Arnsten [10] and Mayes [11]have argued that when arousal exceeds a certain threshold, it is as if aneurochemical switch is thrown.This switch shifts us out of the executivemode of flexible reflective responding into the fight-or-flight mode ofaction-centred responding.Those with insecure or disorganized attachmentrelationships are sensitized during development to intimate interpersonalencounters, experience higher arousal, and the relative level of arousal inthe frontal or posterior part of the cortex overwhelms their executivefunctions more easily than individuals who have experienced a secureattachment relationship.Thus in BPD we have potentially interlockingvicious developmental circles in which attachment disturbance leads toaffective hyperarousal, which in turn results in a failure of mentalization; allare intertwined.This has gained further credence from the work of Rinne etal.[12,13], who found that in BPD severe and sustained traumatic stress in240 __________________________________________________________________ PERSONALITY DISORDERSchildhood affects the serotonin (5-HT) system and especially 5-HT1Areceptors.This appears to be independent of the BPD diagnosis but dependenton the presence of severe trauma, the severity of which may account for theheterogeneity of patients with BPD in terms of symptomatology, pathogenesis,and type of co-morbidity, with less overt trauma having less effect onreceptors and threshold levels of arousal.Hence not all patients with BPDreport neglect and abuse, but those that do show the most severe symptoms[14].This biopsychosocial model has important consequence for treatment.Impulsivity, outwardly directed aggression, and auto-aggression may behelped with medication [15], but mentalization can only develop usingpsychological techniques.Whilst Michael Stone discusses evidence foroutcome of treatment, the question remains about why very differenttreatments, for example dialectical behavioural therapy and psychoanalytictherapy, seem to   work .According to the aetiological stance discussedearlier, if robust psychological change is to take place, the focus of treatmentneeds to be on improving mentalization rather than developing skills tocontrol affective disturbance and dysfunctional behaviour.The greateremphasis on mentalization in the psychoanalytic treatment [16] mayexplain why the follow-up of patients was possibly better for psycho-analytic therapy than behaviour therapy [17].Yet both approaches givesome lasting improvement [ Pobierz całość w formacie PDF ]