Journal of Reproductive and Infant PsychologyAquatic Insects

Vol. 29, No. 3, July 2011, 223235

Motherinfant interactions in women with borderline personality

disorder, major depressive disorder, their co-occurrence, and
healthy controls
Henry Whitea*, T. John Flanaganb, Ariel Martina and David Silvermannc
a
The Chicago School of Professional Psychology, Chicago, USA; bUniversity of Chicago,
Chicago, USA; cWomen and Infants Hospital, Providence, USA
(Received 17 June 2010; nal version received 27 March 2011)

Primary objective: Studies have documented motherinfant interactions in the

context of maternal Borderline Personality Disorder (BPD) to be unpredictable
and disordered. However, no studies have directly compared motherinfant inter-
action between women with BPD and other psychiatric disorders. Methods: The
current study examined motherinfant interactions in the context of women with
BPD, major depressive disorder (MDD), their co-occurrence and healthy controls.
Motherinfant interactions were coded for mother and infant behaviour across a
variety of behavioural dimensions. Main outcomes and results: Group differences
emerged on the domains of maternal smiling, maternal touching, maternal game
playing, maternal imitation, infant smiling, infant vocalisation and infant gaze
aversion. Conclusion: Differences in motherinfant interactions can be reliably
observed across varying forms of psychopathology. Such observed differences
may be used to improve clinical treatment of mothers with psychopathology.
Keywords: borderline personality disorder; major depression; motherinfant
interaction; nonverbal behaviour

Introduction
Borderline personality disorder (BPD) is characterised by affective instability,
impulse control, and impaired interpersonal relationships (APA, 1994). Disturbance
in interpersonal relatedness often serves to differentiate this disorder from Axis I
and other Axis II disorders. For example, Gunderson and colleagues (1996) found
that two interpersonal criteria, avoidance of abandonment and unstable relationships,
differentiated borderline personality disorder from other personality disorders. In
addition, research in the area of attachment theory suggests that early relational
trauma disorganises mental functioning in persons with BPD, particularly in the
capacity to understand selfother relationships (e.g. Fonagy & Target, 1997). More-
over, clinical vignettes suggest that women with BPD often report anxiety and
anger in response to their infants, inability to discern the infants mood and affec-
tive state, and feelings of being overwhelmed in the context of parenting the infant
(Newman & Stevenson, 2005; Hobson, Patrick, Valentine, 1998). Thus, impair-

*Corresponding author. Email: henrywhitepsyd@yahoo.com

ISSN 0264-6838 print/ISSN 1469-672X online

2011 Society for Reproductive and Infant Psychology
DOI: 10.1080/02646838.2011.576425
http://www.tandfonline.com
224 H. White et al.

ments of interpersonal functioning are hallmarks of BPD illness, and may be readily
apparent in the context of motheroffspring interactions.
Several studies have examined the offspring of mothers with BPD, with at least
two studies reporting on infants. One study examined 2-month-old infants and their
mothers, nding mothers with BPD demonstrated more intrusiveness and insensitiv-
ity, with infants demonstrating more dazed looks, more frequent gaze aversion, and
less responsiveness when compared with controls (Crandell, Patrick, & Hobson,
2003). In a second study, infants of mothers with BPD were studied at 13 months,
with 80% identied as disorganised in their attachment with their mothers (Hobson,
Patrick, Crandell, Garcia-Perez, & Lee, 2005), which is the same percentage found
in maltreated children (Carlson, Cicchetti, Barnett, & Braunwald, 1989). In addition,
the investigators found that infants of mothers with BPD were less sociable, and
mothers with BPD were more likely to engage in intrusive behaviour with their
infants. In older children of mothers with BPD, more disruptive behaviour (e.g.
Weiss et al., 1996) and more problems with attention and aggression (Barnow, Spit-
zer, Grabe, Kessler, & Freyberger, 2006) when compared with control comparisons
have been reported. Also, children of mothers with BPD have more anxiety, depres-
sion and low self-esteem when compared with children of mothers with depression,
other personality disorders, and no disorder (Barnow et al., 2006). Such results are
particularly noteworthy given that they indicate the longitudinal impact of BPD ill-
ness on offspring development, as well as the unique impact of maternal BPD on
offspring. Finally, in addition to the documented impact on rates of mood and anxi-
ety, maternal BPD illness may yield impairments in quality of representational
capacities, such as mentalisation (Mace, Rivas, Engle, Hamilton, & Rathjen,
2005).
Impairments in motherinfant interaction are documented in a variety of disor-
ders, such as maternal alcoholism and drug abuse (OConnor, Sigman & Brill,
1987; Rodning, Beckwith, & Howard, 1991), eating disorders (Stein, Woodley,
Cooper, & Fairburn, 1994), psychotic depression and mania (Hipwell, Goosens,
Mellhuish, & Kumar, 2000). However, understanding motherinfant interactions in
the context of BPD is complicated by the fact that the disorder is commonly co-
morbid with Axis I disorders and other personality disorders (PDs). In addition,
several mechanisms suggest the unique contributions of maternal BPD to impair-
ments in motherinfant interaction and communication. First, conceptualizations of
motherinfant interactions in the context of maternal BPD may be understood from
a relational diathesis model (e.g. Lyons-Ruth, Bronfman, & Atwood, 1999). This
model suggests that infants not only experience the relations of other people, but
also identify with and internalise these experiences through the use of early formed
social-cognitive mechanisms. Thus, motherinfant communication may be disturbed
in the context of BPD due to infant internalisation of negative relational schemas
unique to the disorder. Such disturbances may be exacerbated by maternal issues,
such as the frequently documented impairments in mentalisation and reective func-
tioning which are characteristic of BPD illness. Second, BPD diagnosis may simply
be a proxy for a separate, but related, variable which may negatively impact child
outcomes, such as physical abuse of the child or substance/alcohol abuse. For
example, children aged 418 years whose mothers have BPD are more likely than
children of mothers with other personality disorders to experience changes in house-
hold composition and schools attended, removal from the home, and exposure to
parent drug or alcohol abuse and mothers suicide attempts (Feldman et al., 1995).
 Journal of Reproductive and Infant Psychology 225

Also, personality pathology seems to have an impact on family functioning inde-

pendent of depressive pathology (Miller et al., 2000). Finally, motherinfant interac-
tion in the context of BPD may be impaired due to biological factors. For example,
in at least one study, oxytocin implicated in prosocial behaviour, social communi-
cation, evaluation of others, and understanding of internal states was shown to
differentially impact decision-making processes in a social cognition trust task in
persons with BPD compared to control comparisons. Thus, impairment of mother
infant interaction in women with BPD may be result of dysregulated levels of
neurotransmitters responsible for the development and regulation of afliation
behaviour and pair bonding. Finally, children of parents with MDD and BPD had
more cognitive and interpersonal vulnerabilities compared to children of parents
with MDD alone (Abela, Skitch, Auerbach, & Adams, 2005).
The current study sought to extend previous ndings in studies of motherinfant
interaction in the context of maternal BPD by describing the motherinfant interac-
tions in the context of maternal BPD, MDD, their co-occurrence, and healthy con-
trol dyads. Mothers completed diagnostic interviews with a clinical psychologist, in
addition to self-report questionnaires of depression and anxiety. Interactions of 85
mothers and infants were recorded and coded using standardised procedures for the
study of motherinfant interaction. Interactions were coded for maternal variables
of: smiling, touching, vocalisation, limb movement, game playing, imitation and
exaggerated faces and infant variables of: smiling, vocalisation, motor activity, gaze
aversion and crying.

Methods
Participants
All procedures were approved by the Institutional Review Board. Women with
BPD were outpatients in group psychotherapy at an urban, psychiatric hospital. The
study was advertised directly after group meetings using iers and verbal announce-
ments from March 2002 to January 2010. Women were recruited from two univer-
sity hospitals and an OB/GYN clinic.
For the psychiatric population, women were included in the study if they met
the following criteria: (1) current diagnosis of BPD as diagnosed by the Structured
Clinical Interview for DSM-IV Disorders (SCID-IV; First et al., 1997) and the
Diagnostic Interview for Borderline Patients, Revised (DIB-R); or, current diagnosis
of Major Depressive Disorder (MDD) as diagnosed by the SCID-IV interview; or
current diagnosis of both BPD and MDD; (2) were P 18 years old; (3) agreed to
participate in a study visit at 3 months postpartum. Participants were excluded for:
(1) current substance abuse or alcohol abuse; (2) meeting criteria for any other Axis
I mood disorder according to SCID interview; (3) history of brain disease or neuro-
logical disorder. All participants were paid $40.00 for participation. Participants in
the MDD, BPD, and co-morbid participant groups were allowed to enrol in the
study even if they met criteria for other personality disorders, as long as the other
personality disorder(s) were rated as secondary by the interviewer. Of the partici-
pants meeting criteria for BPD, 16 met criteria for at least one additional personality
disorder. The most frequent co-morbid personality disorders were narcissistic per-
sonality disorder (n = 11), dependent personality disorder (n = 8), and histrionic
personality disorder (n = 7). Among women meeting criteria for MDD, 17 women
met criteria for at least one personality disorder. The most frequent personality
226 H. White et al.

disorders found in this sub-sample were schizoid personality disorder (n = 7) and

avoidant personality disorder (n = 7). Of patients meeting criteria for MDD and
BPD, all women met criteria for an additional personality disorder. The most fre-
quent personality disorders in this sub-sample were narcissistic personality disorder
(n = 11) and avoidant personality disorder (n = 8).

Procedure
Following informed consent, women were administered the SCID-IV and the Inter-
national Personality Disorder Examination (IPDE, see Loranger, 1999) by a clinical
psychologist. Women who met criteria for BPD completed the DIB-R. After com-
pleting the interview(s), women scheduled a follow-up visit to complete the
motherinfant interaction task and self-report measures. Diagnoses were conrmed
at the motherinfant interaction visit by the same interviewer from the rst visit.

Measures
Environmental risk scores
Table 1 presents the variables used to compute a cumulative environmental risk
measure. These variables were converted to standard scores and combined into a
cumulative risk score that was scaled to have a mean of 50 and a standard devia-
tion of 10. The range for the sample was 12.3988.83. Such aggregate variables
are more stable than any individual measure, and there is increased power to detect
effects of the environment because errors of measurement decrease as scores are
summed (Wachs, 1991). Similar cumulative environmental risk measures have been
found to account for more variance in child outcome variables than single factors,
including socioeconomic status (Bendersky & Lewis, 1994; McGauhey, Stareld,
Alexander, & Ensminger, 1991; Sameroff, Seifer, Barocas, Zax, & Greenspan,
1987).

Infant temperament
Infant temperament was measured by using the Infant Behaviour Questionnaire,
Revised (IBQ-R; Gartstein & Rothbart, 2003), which is based on the Infant Behav-
iour Questionnaire (Rothbart, 1981), which represents a parent-report assessment
tool, based on the denition of temperament proposed by Rothbart and Derryberry
(1981), work with the Child Behaviour Questionnaire (CBQ; Rothbart, Ahadi, Her-
shey, & Fisher, 2001), as well as other developmental research that had identied
signicant temperament dimensions and associated behavioural tendencies. The
IBQ-R consists of 14 scales (Gartstein & Rothbart, 2003). Reliability and validity
of this parent-report instrument have been documented, with Cronbachs alphas
ranging from .77 to .96 (Gartstein & Rothbart, 2003; Gartstein, Slobodskaya &
Kinsht, 2003). Chronbachs alphas computed for the present sample were: IBQ
Smiling and Laughter = .80; IBQ High Intensity Pleasure = .90; IBQ Activity Level
= .88; IBQ Approach = .80; IBQ Perceptual Sensitivity = .81; IBQ Vocal Reactivity
=.83; IBQ Fear =.97; IBQ Distress to Limitations = .81; IBQ Sadness =.79; IBQ
Falling Reactivity =.79; IBQ Duration of Orienting =.80; IBQ Soothability = .88;
IBQ Cuddliness/Afliation = .90; IBQ Low Intensity Pleasure =.88. Mean and stan-
dard deviations of temperament scale scores are shown in Table 2 by diagnostic
group.
 Journal of Reproductive and Infant Psychology 227

Table 1. Variables constituting environmental risk score.

Variable Scoring
Demographic characteristics
Maternal race 0 = White; 1 = non-White
Maternal living situation 0 = lives with 1 or more adult
1 = lives with child or children
only
No. children under 18 years of age in mothers household Higher no. = higher risk
Maternal social support network size Smaller no. = higher riska
Maternal life stressors Higher no. = higher riskb
Maternal postnatal cocaine use 0 = not used since deliver
1 = used since delivery
Regularity of childs schedule Less regular = higher riskc
Stability of childs surroundings Less stable = higher riskc
No. of regular caregivers More = higher riskc
Maternal level of education 0 = high school graduate
1 = less than high school
education
Main source of income 0 = not on public assistance
1 = on public assistance
Neonatal medical risk
Hobel Neonatal Risk Scale More complications = higher
score
a
Norbeck Social Support Questionnaire (Norbeck, Lindsey, & Carrieri, 1981). bPrenatal Social Environ-
ment Inventory (Orr, James, & Casper, 1992). cFamily Chaos Scale, Family Child Study of Affective
and Anxiety Disorder, Grant MH44755.

Table 2. Temperament subscales diagnostic group.

BPD N = 17 MDD N = 25 BPD+MDD N = 20 HC N = 25
Activity Level 4.23 (.71) 4.10 (1.00) 4.11 (.87) 4.19 (.78)
Distress to Limitations 3.41 (.78) 3.57 (.67) 3.70 (.80) 3.56 (.70)
Fear 4.51 (.77) 2.17 (.68) 4.33 (.80) 2.11 (.67)
Duration of Orienting 3.77 (.67) 3.60 (.71) 3.56 (.81) 3.45 (.69)
Smiling and Laughter 4.61 (.87) 4.33 (.76) 4.26 (.81) 4.15 (.70)
High Intensity Pleasure 5.77 (.34) 5.51 (.70) 5.44 (.77) 5.11 (.87)
Low Intensity Pleasure 4.79 (1.01) 4.71 (1.22) 4.51 (1.01) 4.32 (1.09)
Soothability 2.14 (.81) 3.77 (.83) 3.87 (.79) 3.62 (.71)
Falling Reactivity 4.11 (.72) 4.01 (.64) 4.05 (.76) 4.10 (.76)
Cuddliness 5.01 (1.01) 5.33 (.67) 5.54 (.89) 5.76 (.81)
Perceptual Sensitivity 4.10 (.98) 3.91 (.97) 3.95 (.89) 4.01 (.91)
Sadness 3.01 (.55) 3.19 (.56) 3.22 (.60) 3.32 (.55)
Approach 4.87 (.77) 4.86 (.76) 4.33 (.65) 4.12 (.71)
Vocal Reactivity 4.22 (.90) 4.31 (.66) 4.42 (.70) 4.51 (.69)

Maternal depression and anxiety

The Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) served as
measures of maternal depression and anxiety levels. The BDI is a 21-item instrument
that measures cognitions and symptoms often observed in depressed inpatients. It is
a widely used screening tool for depression. The BAI is a 21-item instrument that
assesses the severity of anxiety symptoms (Beck, Epstein, Brown, & Steer, 1988).
228 H. White et al.

Motherinfant interactions
Mother and infants were seated facing each other, 18 inches apart, with the infant
in an infant seat on a table and the mother seated on a chair at the table. Dyads
were videotaped during the 5-min face-to-face interactions. Mothers were asked to
pretend you are playing with your infant like you would at home. Two video cam-
eras were located behind the infant and the mother, a split-screen generator was
used to record the infant and mother behaviours simultaneously.

Behaviour ratings
Videotapes were scored using a scoring procedure using the Interaction Rating
Scale (Field, 1980), a three-point Likert-scale that includes behaviour ratings for
infant behaviours and maternal behaviours. The coding system has been widely
used in studying motherinfant interaction in a variety of contexts, including major
depression, dysthymia, preterm infants, and polydrug use (cites). For the purposes
of this study, items were scored as present or not-present, instead of optimal func-
tioning, due to nascent stage of research on infants of mothers with BPD (see Field,
1977; Field, Diego, Hernandez-Reif, & Ascencio, 2009). This system was selected
due to the ease of feasibility in training research assistants to utilise it and the high
inter-rater reliabilities that have been reported in the literature using this system.

Coders
Videotapes were coded for mother interaction behaviour and infant interaction
behaviour by research assistants blinded to the hypotheses of the study and diagnos-
tic status of participants using second-by-second coding. Time-linked, split-screen
recordings were coded using separate coding sheets for each second. Each second
was coded for the presence or absence of the specic behaviour. Total percent of
time for each behaviour were then calculated based on these second-by-second
codes. In preparation for coding the current study, research assistants coded 10 vid-
eotapes that had been coded by an expert coder. All research assistants achieved a
level of 95% reliability with an expert coder. As a measure of inter-coder reliability,
two coders coded videotapes of 15 dyads randomly selected from the current sam-
ple. Kappa coefcient for the current study was .93.

Data analysis
All data analysis was completed using the Statistical Package for the Social Sciences
(SPSS, Chicago, IL). Distributions of continuous variables were examined for normal-
ity. For variables with positive skewed distributions, log transformations were per-
formed. Variables with large percentages of zero counts were dichotomised. A Duncan
Multiple Range test was used to identify potential covariates. Group differences were
examined using MANCOVAs followed by post-hoc univariate ANCOVAS.

Results
Demographics and maternal and infant clinical characteristics
Two hundred and seventeen women sought enrolment in the study. A phone screen-
ing interview was conducted to determine initial eligibility. Of the 217 interviewed,
 Journal of Reproductive and Infant Psychology 229

198 women were invited for participation in the study, with 19 participants being
excluded due to ineligible Axis I diagnoses. Of the 198 women interviewed, 102
women were excluded due to: ineligible Axis I diagnosis (n = 66), current sub-
stance or alcohol abuse/dependence (n = 21), infant malformations or difculties at
birth (n = 5), multiple missed appointments (n = 8), failure to conrm diagnoses at
second interview (n = 2). Finally, 9 women recruited for the study were excluded
due to camera malfunction during recording of the interaction or failure to under-
stand directions, yielding a nal sample of 87 women. Women who were inter-
viewed but excluded were compared to the nal sample across all demographics
and no signicant differences were observed. The nal sample consisted of 62
women with a psychiatric diagnosis (MDD, N = 25; BPD+MDD N = 20, BPD N =
17) and 25 healthy controls and their infants. The mean age of the infants was 3.52
months, with the sample consisting of 41 female and 44 male infants. Mothers had
a mean age of 29.8 (SD = 3.6). Ethnic distribution of the sample was 57.5% White,
17.2% Black, 11.49% Latina, 6.9% Asian, 6.9% Other. Of the women, 72% were
college-educated and 86.2% of women were partnered.
A summary of maternal and infant characteristics can be found in Table 3. Dun-
can Multiple Range tests indicated that both women with BPD and women with
BPD+MDD consumed more alcohol during pregnancy compared with healthy con-
trols (p = .05) but did not signicantly differ from each other or from women with
MDD. Current severity of depression signicantly differed between groups. Accord-
ing to the BDI, women diagnosed with co-morbid BPD+MDD reported higher lev-
els of depression when compared with women with BPD (p = .04) and healthy
controls (p = .02), with no signicant differences between women with MDD. In
addition, women with MDD reported signicantly higher levels of depression
according to the BDI when compared with women with BPD (p = .03) and healthy
controls (p = .01). Finally, BDI scores signicantly differed between women with
BPD and control comparisons (p = .05).
Post-hoc analyses indicated that infants of mothers with BPD and BPD+MDD
had higher scores on fear when compared with infants with MDD (p = .06) and
control comparisons (p = .07). In addition, infant soothability was signicantly
lower in infants of mothers with BPD when compared to other groups. Finally,
there was a trend for differences in environmental risk scores that indicated that
infants of BPD women and BPD+MDD women had higher environmental risk
when compared with both infants of MDD women (p = .09) and control compari-
sons (p = .05).
As a result of these differences, alcohol consumed during pregnancy, maternal
severity of depression, infant soothability and infant fear and environmental risk
scores were controlled for in subsequent analyses.
Two one-way, between-subjects MANCOVAs (one for adult behaviour rat-
ings and one for the infant behaviour ratings), grouped according to diagnostic
group, were used to assess group difference in mother and infant interaction
variables. Infant soothability, infant fear, maternal depression and number of
alcoholic drinks consumed during pregnancy served as covariates. The overall
multivariate statistic was signicant using Pillais Trace Criterion for the infant
variables (F(2,86) = 4.01, p = .02) and the maternal variables (F(2,84) = 3.31,
p = .02).
Table 4 presents the means, standard deviations, and means adjusted for the
covariates, as well as percentage of mother and infant behaviour.
230 H. White et al.

Table 3. Characteristics of current sample.

Group BPD N = 17 MDD N = 25 BPD+MDD N = 20 HC N = 25
Ethnicity 47.06% 40.0% 45.0% 40.0%
(% non-white)
Gender of infant 52.94% 56% 60% 52%
(% males)
Infant age (days) 98 (5.01) 99 (4.11) 101 (4.39) 100 (4.55)
Maternal age 30.01 (3.11) 29.87 (3.01) 29.00 (4.01) 30.01 (3.76)
(years)
Environmental 75.52 (10.01) 21.89 (6.80) 70.22 (8.19) 18.88 (5.99)
Scores
(range 0100)
Partnered (% not 11.76% 12.0% 15.0% 16.0%
partnered)
Current smoking 3.01 (5.01) 4.09 (5.88) 3.79 (5.09) 3.20 (3.01)
(cigarettes per
week)
Smoking 1.01 (1.11) 1.01 (1.01) 1.22 (1.22) .99 (1.01)
pregnancy
(cigarettes per
week)
Current alcohol 1.91 (1.55) 2.01 (1.56) 2.11 (1.67) 1.80 (1.33)
use (drinks per
week)
Alcohol use 2.98 (1.78) .09 (1.01) 3.01 (2.01) .11 (.98)
during
pregnancy
(drinks per
week)
Beck Depression 18.01 (3.01) 22.77 (4.44) 22.01 (4.22) 3.44 (3.01)
Inventory
Beck Anxiety 6.80 (2.01) 5.71 (3.50) 5.85 (2.22) 3.01 (2.22)
Inventory
Number of 1.99 (1.11) 1.34 (.42) 2.22 (1.61) n/a
co-morbid PDs

Mother variables
Based on a signicant nding in the MANCOVA, a series of univariate ANCOVAs
were conducted controlling for infant soothability, infant fear, maternal depression
and number of alcoholic drinks consumed during pregnancy. Results indicated that
smiling was greater in mothers with MDD when compared with mothers with BPD
(F(1,40) = 3.01, p < .05) and mothers with BPD+MDD (F(1,35) = 3.02, p < .05).
Healthy control mothers smiled signicantly more often than mothers with MDD (F
(1,48) = 3.33, p < .05), more often than mothers with BPD (F(1,40) = 3.77, p <
.05), and more often than mothers with BPD+MDD (F(1,42) = 3.21, p < .05).
Women with MDD displayed more touching when compared with women with BPD
(F(1,39) = 3.03, p < .05) and women with BPD+MDD (F(1,43) = 3.88, p < .05).
Mothers with MDD engaged in more game playing when compared to mothers with
BPD (F(1,41) = 3.77, p < .05) and mothers with BPD+MDD (F(1,43) = 3.91, p <
.05). Healthy control mothers engaged in more game playing when compared with
mothers with BPD (F(1,40) = 3.51, p < .05) and mothers with BPD+MDD (F(1,44)
= 3.55, p < .05). Finally, mothers with BPD engaged in less imitation when com-
 Journal of Reproductive and Infant Psychology 231

pared with mothers with MDD (F(1,40) = 3.45, p < .05), mothers with BPD+MDD
(F(1,36) = 3.01, p < .01) and healthy control mothers (F(1, 41) = 3.67, p < .05).

Infant variables
Based on a signicant nding in the MANCOVA, a series of univariate ANCOVAs
were conducted controlling for covariates previously identied. Infants of mothers
with MDD engaged in more frequent smiling when compared with infants of
mothers with BPD (F(1,41) = 3.45, p < .05) and when compared with infants of
mothers with BPD+MDD (F(1,44) = 3.55, p < .05). Infants of control comparisons
engaged in more frequent smiling when compared with infants of BPD mothers
(F(1,40) = 4.05, p < .05) and infants of mothers with BPD+MDD (F(1,43) = 4.11,
p < .05). On the dimension of vocalisation, infants of mothers with MDD engaged
in greater vocalisation when compared with infants of mothers with BPD (F(1,41)
= 4.55, p < .05) and infants of mothers with BPD +MDD (F(1,40) = 4.05,
p < .05). Infants of control comparisons engaged in greater vocalisation when com-
pared with infants of BPD mothers (F(1,41) = 4.01, p < .05) and compared with
infants of BPD+MDD mothers (F(1,43) = 4.77, p < .05). Also, infants of MDD
mothers averted gaze with mothers more often than infants of mothers with BPD
(F(1,40) = 4.05, p < .05). Infants of MDD mothers averted gaze more often than
infants of healthy control mothers (F(1,47) = 4.04, p < .05). Finally, infants of
mothers with BPD+MDD averted gaze with mothers more often than infants of
healthy control mothers (F(1,43) = 4.76, p < .05) and infants of mothers with BPD
(F(1,34) = 3.01, p < .05).

Discussion
This is the rst report to compare motherinfant interaction among women with
MDD disorder, BPD, and their co-morbidity. Our results suggest that several vari-
ables of mother and infant positive interaction behaviour are disturbed within the

Table 4 Means for motherinfant interaction behaviours at 3 months for women with Borderline
Personality Disorder, Major Depression Disorder, and their co-occurrence, and healthy controls.
Behaviours (% time) BPD MDD BPD+MDD HC F p
N = 17 N = 25 N = 20 N = 25
Mothers
Smiling 7.7% 16.1% 7.8% 33.1% 4.56 .05
Touching 30.1% 62.4% 31.7% 62.9% 4.75 .04
Vocalisation 32.2% 33.1% 33.6% 35.5% .77 ns
Limb Movement 12.2% 11.0% 12.5% 10.1% 1.01 ns
Game Playing 3.0% 12.1% 3.7% 9.1% 4.78 .05
Imitation .25% 4.5% 3.9% 6.9% 5.89 .01
Exaggerated Faces 1.2% 1.8% 1.5% 1.2% .76 ns

Infants
Smiling 12.2% 39.5% 12.4% 41.1% 4.44 .05
Vocalisation 19.2% 33.4% 19.8% 34.4% 2.99 .05
Motor Activity 13.3% 11.6% 14.5% 10.1% .91 ns
Gaze Aversion 27.4% 43.3% 48.7% 22.1% 6.33 .001
Crying 3.3% 4.6% 2.9% 2.5% .45 ns
232 H. White et al.

context of BPD. In the current report, maternal touching and maternal game playing
were signicantly reduced in mothers with BPD (with or without MDD) compared
to the MDD group and HC (healthy control) group. In addition, frequency of mater-
nal smiling signicantly differed between the HC group, the MDD group, and both
BPD groups. Finally, only maternal imitation emerged as a dimension that was only
impaired in the context of pure BPD. On infant dimensions, no signicant differ-
ences emerged between infants of MDD mothers and HC mothers on the dimension
of smiling or vocalisation, but infants of mothers with MDD (with or without BPD)
engaged in greater gaze aversion when compared with infants of HCs and BPDs.
Taken together, our results allude to the differential impact of BPD and major
depressive disorder on quality of early motherinfant interaction.
Fourteen infant temperament qualities were evaluated in the current sample of
infants, with only two yielding differences within the sample and, thus, being sub-
sequently controlled for. Obtaining temperament scores provided an ability to dis-
cern if the observed effects are the result of impairment in overarching temperament
behaviour or uniquely specic to interactions with the mother. For example, in at
least two instances (e.g. infant vocalisation and infant smiling/laughter), nearly iden-
tical variables are collected during the motherinfant interaction and temperament
evaluation. However, although no differences were observed in the temperamental
variables on either of these domains, both domains had signicant differences
within the motherinfant interaction. Second, temperament differed between diag-
nostic groups on only 2 of the 14 scales and, overall, yielded no signicant differ-
ences on total scores. This result is noteworthy in and of itself given that several
studies have suggested that parental psychopathology does inuence infant tempera-
ment. Thus, these results are indicative of two potential conclusions. First, given
that the IBQ-R was used, which is a maternal self-report instrument of infant tem-
perament, mothers with BPD and to some extent MDD may be poor judges of
infant temperament behaviour. Second, these results suggest that individual differ-
ences between diagnostic groups may only be apparent in the context of mother
infant interactions and not in the wider spectrum of environments that the tempera-
ment measure includes. Given that parent-reported infant temperament is typically
considered as one of the earliest reliable predictors of later behaviour problems
(Keenan, Shaw, Delliquadri, Giovannelli, & Walsh, 1998) and psychiatric diagnosis
during adolescence (Teerikangas, Aronen, Martin, & Huttunen, 1998), future studies
should continue to examine how temperament and quality of motherinfant interac-
tion are related in the context of mothers with BPD, MDD, and their co-morbidity.
Several results in the current paper seem counter-intuitive and should be tied
into an existing literature. First, previous reports of motherinfant interaction in the
context of BPD have indicated that infants of mothers with BPD experience greater
gaze aversion when compared with infants of control comparison mothers. Results
of this study partially replicate this nding by indicating that infants of mothers
with BPD have reduced gaze aversion compared with control comparisons; how-
ever, our results suggest that gaze aversion is higher in infants of mothers with
MDD and MDD+BPD when compared with BPD. However, the previous study
only utilised a sample of 8 mothers, and compared these mothers to 8 control moth-
ers, with no evaluation of an MDD or co-morbid group. Second, women with BPD
alone imitated their infants less when compared with women with MDD or MDD
+BPD. This nding is particularly interesting given that intuitively, one would
expect that the additive effect of psychopathology.
 Journal of Reproductive and Infant Psychology 233

First, the relationship between MDD and BPD is unclear. Moreover, samples
reporting on persons with BPD and no co-morbid diagnosis are practically non-exis-
tent in the extant literature, mostly because they are extremely rare cases and thus,
often have clinical application. As such, we have little in the way of existing
research to serve as a comparison to the current study. The extreme difculty in
recruiting such a sample alludes to a question about the existence of BPD separate
from depressive disorders. In the current paper, enrolment was not excluded based
on past history of mood disorders. Thus, it is possible that previous history of psy-
chopathology, particularly mood disorders, may have confounded some of our
results. To this end, it is possible that the sample of BPD+MDD and BPD group
were actually very similar, and that a majority of members in the pure BPD group
were simply outside of a recent mood episode, but not uniformly non-depressed.
Next, severity of BPD illness and numbers of BPD symptoms were not controlled
for. Indeed, previous reports on persons with BPD have indicated that differences in
symptom severity and presence or absence of symptoms (e.g. self-injury, binge eat-
ing, substance abuse) may contribute to differences within a BPD diagnosed group.
Finally, the nding related to maternal imitation of infant behaviour requires dis-
cussion. In the current paper, impairment of this maternal behaviour was only
observed in women with BPD. This nding is particularly noteworthy given that the
rate of maternal imitation in women with BPD is far less when compared with
women with BPD+MDD. One hypothesis that may explain this nding is that
women with BPD without a co-morbid mood disorder may represent a unique, rare
population that have a specic and unique set of emotional and psychological distur-
bances. For example, clinical reports of BPD highlight the importance of impairments
of mentalisation, the capacity to understand the mental states of self and other (Bat-
eman & Fonagy, 2004), in the development and etiology of BPD, and it is highly
likely that impairments in mentalisation are partly represented by impairments in
maternal imitation. Thus, one hypothesis for the difference in rates of maternal imita-
tion seen between BPD and BPD+MDD is that processes related to mentalisation and
understanding of self/other capacities may be different between these two groups.
Future studies should attempt to compare rates of imitation and other mentalisation
processes between BPD mothers and women with other forms of psychopathology,
as well as co-morbidity. Finally, emerging evidence that highlights the cognitive pro-
cess of ruminationa process widely understood to be implicated in major depres-
sionin borderline personality disorder (e.g. Selby & Joiner, 2009) may provide a
potential useful framework for understanding how MDD, BPD, and their co-morbid-
ity are associated with differential forms of emotional and behavioural dysregulation.
Despite the considerable contribution of our report, our study has a number of
limitations. First, we neglected to collect information on the specic medications
used by our participants, and thus the contribution of medication status is unclear.
Second, despite the fact that we used a coding method that has been used previ-
ously in the study of the motherinfant interaction, it is unclear if this coding sys-
tem is entirely appropriate for the study of infants exposed to mothers with BPD.
Indeed, the system used in the current report is over 30 years old, and many more
sophisticated systems now exist for coding of mother and infant interaction. Future
studies should use alternate methods of evaluating motherinfant behaviour. Despite
these limitations, we believe that study contributes extensively to the study of BPD
in the context of the motherinfant interaction. In addition, our report is strength-
ened by the fact that women were diagnosed using multiple structured clinical
234 H. White et al.

interviews. In addition, though these ndings should be replicated in a larger sam-

ple size, our sample sizes are substantially larger than other reports on a similar
population (e.g. Crandell et al., 2003).

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