Exploring the Relationship between Borderline Personality Disorder and Epistemic Trust in Adolescents Elise Draper D.Clin.Psy. Thesis (Volume 1) 2017 University College London UCL DOCTORATE IN CLINICAL PSYCHOLOGY THESIS DECLARATION FORM I confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. Signature Name: Elise Draper Date: 22nd June 2017 2 Overview Borderline personality disorder (BPD) is a complex disorder that is associated with a range of functional, emotional and inter-personal difficulties. In recent years, consensus regarding whether or not BPD should be diagnosed in childhood and adolescence has altered, moving from the view that such a diagnosis is potentially harmful, to observations that the diagnosis may in fact be beneficial, by increasing understanding about young people‟s difficulties and improving access to timely and formulated interventions. Developmental theories of BPD have placed difficulties in mentalizing, and more recently difficulties with epistemic trust, at the core of BPD. However the nature of these difficulties remains unclear. This thesis therefore aims to explore and clarify the relationship between mentalizing abilities, epistemic trust and BPD in adolescence. Part one is a literature review which aimed to critically assess studies that have investigated the relationship between mentalizing and BPD symptomology in young people. The review revealed the challenges that are associated with the assessment of mentalizing in young people, due to the complexity of mentalizing as a psychological construct and the challenges associated with measuring and assessing mentalizing abilities. Although there is an overall lack of clarity among findings, a body of evidence appears to be emerging to suggest that a relationship exists between hypermentalizing and BPD symptomology in young people. Part two is an empirical research paper which explored the relationship between epistemic trust and BPD symptomology in adolescents. It investigates whether severity of BPD symptomology is associated with performance on tasks designed to measure epistemic trust. Additionally, the relationships between psychopathology, relationship difficulties and epistemic trust were also explored. No support was found for the hypothesis that BPD symptom severity is associated with reduced epistemic trust in adolescents. However, there was mixed support for the 3 hypotheses that there is an association between psychopathology and lower levels of epistemic trust, and relationship difficulties and lower levels of epistemic trust. Reasons for these findings are explored and implications for future research and clinical practice are considered. This study was conducted as part of a joint project (Greisbach, 2017; Reches, 2017). Part three presents a critical appraisal of the research project, which provides reflections on the difficulties and benefits associated with diagnosing BPD in adolescence, the difficulties associated with measuring complex psychological constructs and methodological challenges that occurred when carrying out the research project, alongside reflections on the research process as a whole. 4 Table of Contents THESIS DECLARATION FORM .............................................................................2 OVERVIEW..............................................................................................................3 LIST OF TABLES ...................................................................................................7 LIST OF FIGURES ..................................................................................................7 ACKNOWLEDGEMENTS .......................................................................................8 PART 1: LITERATURE REVIEW ........................................................................... 9 ABSTRACT............................................................................................................. 10 INTRODUCTION ....................................................................................................12 METHOD ............................................................................................................... 21 RESULTS .............................................................................................................. 23 DISCUSSION.......................................................................................................... 53 REFERENCES ....................................................................................................... 62 PART 2: EMPIRICAL PAPER ............................................................................... 76 ABSTRACT............................................................................................................. 77 INTRODUCTION ................................................................................................... 79 METHOD ............................................................................................................... 92 RESULTS ..............................................................................................................103 DISCUSSION ........................................................................................................114 REFERENCES ..................................................................................................... 126 PART 3: CRITICAL APPRAISAL ........................................................................ 138 REFERENCES ..................................................................................................... 149 APPENDICES........................................................................................................ 154 APPENDIX A: Assessment criteria of Quality Assurance Checklist .....................155 APPENDIX B: Epistemic Trust Instrument (ETI)....................................................136 APPENDIX C: Trust Game ......................................………………………………...178 5 APPENDIX D: Borderline Personality Disorder Features Scale for Children (BPFSC)………………………………………………………………………………... 181 APPENDIX E: The Strengths and Difficulties Questionnaire (SDQ).................... 184 APPENDIX F: UCL ethical approval confirmation................................................186 APPENDIX G: NHS ethical approval confirmation ………………….....................188 APPENDIX H1: Participant information sheet – clinical adolescent version……. 194 APPENDIX H2: Participant information sheet – clinical parent version ………….199 APPENDIX H3: Participant information sheet – community adolescent version..105 APPENDIX H4: Participant information sheet – community parent version ……. 210 APPENDIX I1: Adolescent over 16 years consent form – clinical sample ……… 215 APPENDIX I2: Adolescent over 16 years consent form – community sample …. 218 APPENDIX J1: Parental consent form – clinical sample …………………………. 221 APPENDIX J2: Parental consent form – community sample …………………….. 225 APPENDIX K1: Assent form – Clinical sample……………………………………...226 APPENDIX K2: Assent form – Community sample ……………………………….. 229 APPENDIX L: Correlation Matrix for Independent and Dependent variables….. 232 APPENDIX M: Correlation Matrix for Demographic and Dependent variables .... 235 APPENDIX N:Joint project contributions…………………………………………... .236 6 List of Tables Part One: Literature Review Table 1 Study Inclusion and Exclusion Criteria……………………….……….. 22 Table 2 Summary description of included studies…………………………....... 25 Table 3Quality rating of studies included in review………………..……………. 33 Part Two: Empirical Paper Table 1Participant demographic information………………………....………….. 103 Table 2 Factor Analysis for Trust Game…………………………….…………... 104 Table 3 Factor Analysis for ETI……………………………………….………..… 105 Table 4 Correlations between BPFSC scores and epistemic trust scores...… 108 Table 5 Correlations between SDQ scores and epistemic trust task scores… 110 List of figures Part Two: Empirical Paper Figure 1 An example of a dilemma on the ETI Instrument …………………….. 95 7 Acknowledgements Firstly, I would like to thank every young person that so generously gave up their time to participate in this study. It was a real privilege to meet such interesting and enthusiastic young people. I would also like to dedicate thanks to my supervisor Professor Peter Fonagy, for allowing me the opportunity to carry out research in such an interesting and thought provoking area. I am grateful for Peter‟s vast knowledge and patience throughout this project. I would also like to thank my second supervisor, Dr Tobias Nolte, for his support and the reassuring advice he offered. A huge thank you goes to the two other trainees working on this joint project, Tal and Jessie, who provided amazing support and were a real pleasure to work with. I would also like to thank my family and boyfriend for all of their encouragement to me throughout the research process. 8 Part 1: Literature Review Examining the Relationship between Mentalizing Difficulties and Borderline Personality Disorder in Young People 9 Abstract Aims The developmental model of Borderline Personality Disorder (BPD) places difficulties with mentalizing at the centre of the problems experienced by young people with BPD. However research into the form that these mentalizing difficulties take have provided heterogeneous results. This review aims to critically assess studies which have investigated the relationship between mentalizing abilities