The role of attachment characteristics in dialectical behavior therapy for patients with borderline personality disorder.

Attachment characteristics play a key role in understanding borderline-specific problems with respect to childhood maltreatment. The aim of this study was to investigate how attachment representations may influence the trajectory of change in a one-year outpatient Dialectical Behavior Therapy (DBT) for patients with Borderline Personality Disorder (BPD). Attachment representations were assessed in 26 BPD patients and 26 healthy controls (HC) using the Adult Attachment Projective Picture System (AAP; George & West, 2012) before treatment. Borderline- and global symptom severity and interpersonal problems were examined before, during and after completing the intervention. ANOVA and stepwise hierarchical regression analyses were used to explore the course of symptomatology. As expected BPD patients displayed a predominance of unresolved attachment in the AAP compared to HC, by showing a lack of ability to integrate attachment related trauma. While both, resolved or unresolved attachment groups revealed significant improvement in symptom severity during treatment, dimensional AAP scores showed differences. Patients with higher scores in "synchrony" demonstrated more indicators of mutual care in their narratives to dyadic pictures and displayed a significantly stronger decrease of interpersonal problems than patients with lower synchrony scores. Assessing attachment representations prior to DBT might provide a helpful insight into individual attachment related resources or lack of these capacities. Responsiveness and synchrony in dyadic interactions with significant others are crucial for healthy interpersonal relations. A stronger therapeutic focus on the patient's capacity to show synchrony in dyadic attachment situations might improve the patient's interpersonal problems towards sensitive and mutual interaction.