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Bon: I found an interview with Dr. Leland Heller about Borderline Personality Disorder. He does a good job explaining the pain associated with the disorder… Here are some excerpts. The entire interview can be read here.

Diagnosing Borderline Personality Disorder And Finding Treatment That Works

Dr Heller: Good evening, It’s great to be here. I have a way of explaining the Borderline Personality Disorder in layman’s terms that might be useful. It’s how I explain it to patients and their families.

Imagine you had a pet dog and it runs into the street and by accident it’s hit by a car. The dog’s leg is broken and it limps off into an alley to lick it’s wounds. A friend of yours sees the dog and comes over to help. The dog is now feeling trapped and cornered – a “wounded animal” – and misinterprets the friend’s attempts to help. The dog snaps at the friend’s hand who is trying to help. The BPD (Borderline Personality Disorder) is a malfunction in the brain’s trapped or “cornered” animal area. Under stress, a seizure develops in that area. That’s why under stress, while raging, a borderline will say to him or herself: “Why am I doing this” – yet be unable to stop it. It’s a seizure – nerve cells firing inappropriately and out of control.

David: And the cause of Borderline Personality Disorder?

Dr Heller: The BPD has many causes including head trauma and brain infections, but it appears that emotional hurts literally damage the brain. Most likely the brain’s support cells – the 90% of brain cells called “glial cells” – are damaged by traumas, causing the person to overreact to stress once puberty strikes. During puberty the brain’s limbic system goes into “overdrive” and adolescents are at their highest risk of seizures in their lifetime. “Sticks and stones may break my bones…but names cause brain damage.” So does incest, abuse, severe trauma, head injuries, attention deficit disorder, and other causes.

David: From my understanding, one of the biggest difficulties facing individuals who have BPD is maintaining stable relationships. This is a great cause of consternation for those people who are on the other side of the relationship. What causes this?

Dr Heller: There are a number of problems. The three most significant are 1) inappropriate mood swings; 2) misinterpretation of motives; and 3) remembering those misinterpreted motives as real. Oftentimes self-fulfilling prophecies occur, and self-hate eventually leads to a significant other coming to the same conclusion – that the individual isn’t worth being with.
…
janet: Would you please tell us more about the self-hate characteristic and how that damages the BPD or his/her relationships?

Dr Heller: Much of it comes from self-destructive behaviors that are used to stop the horrible pain of dysphoria; anxiety, rage, depression and despair. When an individual behaves out-of-control, in a manner that’s inconsistent with their beliefs or normal choices, terrible self-hate develops. Additionally many individuals had low self-esteem and related problems since childhood and are in an environment that causes self-hate to flourish.

crazy32810: How is self-injury related to BPD?

Dr Heller: We all injure ourselves to stop noxious neurological sensations. Interestingly we do it in a linear manner, ripping the skin. A common noxious neurological sensation is the toxins released with an insect bite. BPD dysphoria is about as bad as it gets. The pain is horrible. Many individuals have broken major bones and declared the pain of the fracture was nowhere as severe as dysphoria. When an individual with the BPD discovers that self-mutilation, or other techniques of self injury, work to temporarily stop the pain of dysphoria – they’ll do what it takes to stop it. This is no different than the individual with a fracture wants pain medication. I broke my shoulder last December and I tried to deal with it without taking narcotics. I was foolish and wrong. The pain was so bad it needed to be treated medically. Once individuals with the BPD have their chronic symptoms stabilized, and have safe medication options that work for dysphoria, the self-destructive patterns are no longer needed to stop their pain.

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Neurobiology Informs Successful Psychotherapy for BPD

Mark Moran

A common feature of all psychotherapies for borderline personality disorder is activation of the prefrontal cortex through reappraisal of painful affect states generated by a hyperactive amygdala.

Neurobiological research can help psychotherapists tailor talking therapies to the individual characteristics of patients with borderline personality disorder (BPD).

That’s what Glen Gabbard, M.D., told psychiatrists at this year’s APA annual meeting in Honolulu in an address titled, “Neurobiologically Informed Psychotherapy of Borderline Personality Disorder.”

A prominent psychoanalyst and psychodynamic therapist, Gabbard said he believes the theoretical constructs of psychoanalysis—drives and conflicts—find expression in, and can be interpreted within, a patient’s individual neurobiology. “You can see psychoanalytic meaning at the same time you are looking at biology,” he said. “This was the dream of Freud, to build bridges between psychoanalytic concepts and a neurobiological science of the brain.”

He is the Brown Foundation Professor of Psychoanalysis and professor and director of the Baylor Psychiatry Clinic.

In the case of BPD, Gabbard stressed the role of hyper-reactivity of the amygdala, and a corresponding inactivity of the prefrontal cortex, as well as emerging evidence that patients with BPD have an opioid deficiency. These neurobiological characteristics account for the emotional dysregulation and impulsivity common in BPD (see Key Points Concerning Neurobiology and Psychotherapy for BPD).

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Key Points Concerning Neurobiology and Psychotherapy for BPD There are common therapeutic elements in all of the psychotherapies for BPD, most notably activation of the prefrontal cortex to bring “thinking” to bear on unbearable affects produced by amygdala hypersensitivity.  An opioid deficit appears to be prominent in BPD. Patients with BPD ○ have difficulty deriving satisfaction from intimate relationships, ○ often say they experience emotional pain as physical pain, ○ often resort to cutting themselves for release of endogenous opioids, ○ show a high rate of opioid abuse. Neurobiological research can help clinicians tailor psychotherapies to the needs of individual patients. Some evidence has emerged indicating that BPD patients with dissociative symptoms may not respond as well to dialectical behavior therapy as other patients, suggesting that other treatments may be needed for this subgroup.

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“What’s exciting to me is that the neurobiological research gives us an opportunity to get more specific about tailoring psychotherapies to specific borderline patients,” Gabbard said. “There is a spectrum to BPD, and one of the principles we learn in medical school is to adjust the treatment to the patient, not the patient to the treatment.

“Our psychotherapeutic theories are often like churches or belief systems, and the more we can get science involved in knowing how to tailor therapies to the individual’s neurobiology, the more we are a science rather than a religion.”

He noted, as an example, that recent research indicates that BPD patients with dissociative symptoms may not respond as well to dialectical behavior therapy, suggesting that this subgroup of patients may need to be treated with a different approach.

Gabbard said the psychotherapies that have been proven effective in the treatment of BPD probably all “speak” to common neurobiological processes, but one especially prominent feature is the activation of the prefrontal cortex through active reappraisal of emotions generated by an overactive amygdala. “A feature common to all of the therapies is the emphasis on self-reflection and mindfulness in which one is trying to look inward and manage painful affect states,” he said. “If you are actively reappraising, that appears to cause activation of the prefrontal cortex, which then modulates the amygdala” (Psychiatric News, April 1).

And he added that patients will often experience emotional pain in a physical way that is unbearable. Research by Prossin and colleagues published in the American Journal of Psychiatry in May 2010 implicates an opioid deficiency in BPD, possibly accounting for the high rate of opioid abuse among patients, as well as the high number of borderline patients among those who seek out opioids from physicians and hospitals or from illicit sources. And it is likely that the phenomenon of “self-cutting,” so common in borderline patients, is related to the release of endogenous opioids that accompanies cutting.

“Opioids are involved in emotion regulation and social functioning, so it makes conceptual sense that deficits in endogenous opioids could be related to the ubiquitous dysfunction in social and interpersonal relationships,” he said.

Also intriguing is the fact that patients with BPD report feeling euthymic—as opposed to euphoric—when using opioids, suggesting the neurobiologically determined difficulty they may have experiencing pleasure.

“This means satisfaction in intimacy is going to be challenging and is linked to the insecure attachment that patients experience over and over,” Gabbard said. “So when we see these people having difficulty forming a therapeutic alliance, it is so important that therapists not think of them as ‘difficult’ or ‘bad’ patients, but as people who are struggling with a biological deficit they are trying to overcome in order to link up with someone in a way they may never have experienced.”

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Mind Reading: Psychologist Simon Baron-Cohen on Empathy and the Science of Evil
By MAIA SZALAVITZ Monday, May 30, 2011

Cambridge psychology professor and leading autism expert Simon Baron-Cohen is best known for studying the theory that a key problem in autistic disorders is “mind blindness,” difficulty understanding the thoughts, feelings and intentions of others. He’s also known for positing the “extreme male brain” concept of autism, which suggests that exposure to high levels of testosterone in the womb can cause the brain to focus on systematic knowledge and patterns more than on emotions and connection with others. (Oh, and yes, he’s also the cousin of British comedian Sacha “Borat” Baron Cohen.)

Baron-Cohen’s new book, The Science of Evil: On Empathy and the Origins of Cruelty, examines the role of empathy, the ability to understand and care about the emotions of others, not only in autism but in conditions like psychopathy in which lack of care for others leads to antisocial and destructive behavior.

What do you mean when you write about “zero negative” empathy?

Zero empathy refers to people at the extremely low end of the scale. They tend to be people with personality disorders, particularly antisocial personality disorder (ASPD). I focus quite a lot on psychopathy [the extreme form of ASPD] and also on two other personality disorders, borderline personality disorder and narcissistic personality disorder.

The ‘negative’ is meant to be shorthand for this being negative for the individual but also for the people around them. It’s meant to contrast with what I call ‘zero positive’ empathy, which effectively describes the autistic spectrum.

[Autistic people] struggle with empathy just like zero negatives but it seems to be for very different reasons. I’m arguing that their low empathy is a result of a particular cognitive style, which is attentive to details and patterns or rules, which in shorthand, I call systemizing.

If we think about the autism spectrum as involving a very strong drive to systemize, that can have very positive consequences for the individual and for society. The downside is that when you try to systemize certain parts of the world like people and emotions, those sorts of phenomena are less lawful and harder to systemize. That can lead to having low empathy, almost like a byproduct of strong systemizing.

How do you account for people who are both highly empathetic and highly systematic, such as some of those with Asperger’s who are actually oversensitive to the emotions of others?

I’ve certainly come across subgroups like that. There are people with Asperger’s whom I’ve met who certainly would be very upset to learn they’d hurt another person’s feelings. They often have very strong moral consciences and moral codes. They care about not hurting people. They may not always be aware [that they've said something rude or hurtful], but if it’s pointed out, they would want to do something about it.

The other side of their moral sense is that they often have a strong sense of justice or fairness. They may have arrived at it through looking for logical patterns rather than necessarily because they can easily identify with someone, however.

People often think that autistic people are dangerous, like psychopaths, when they hear this idea that they have “no empathy.”

In a way, that was one of my motivations for writing the book. Low empathy is a characteristic of many different conditions or disorders. Often books are written where they either focus on psychopathy or autism but [not both].

We have to look at them side by side, and when we do that, we see that they are very different and it’s important to bring that out.

Is it the case, then, that autistic people are not good at the “mind reading” part of empathy, in terms of predicting people’s behavior and feelings, while psychopaths are able to do that but are not able to care?

I think the contrast between these two conditions provides some evidence for that dissociation within empathy. People with psychopathy are very good at reading the minds of their victims. That’s probably most clearly seen in deception. You have to be good at mind reading before it would even occur to you want [to deceive someone]. So you can see the cognitive part of empathy as functioning very well, but the fact that they don’t have the appropriate emotional response to someone else’s state of mind, the feeling of wanting to alleviate distress if someone’s in pain, [that suggests that] the affective part of empathy is not functioning normally.

What stunts the development of empathy in personality disorders?

In the book, I explore both early environmental factors and biological and genetic factors. I think it’s particularly clear in borderline personality disorder (BPD) that there’s a strong association between early environmental deprivation and neglect and abuse and later outcome of BPD. There’s an association [with abuse and trauma early in life] in psychopathy, but it’s not strong as in BPD.

What defines borderline personality disorder?

There seems to be quite a lot of difficulty in self-regulation, in the regulation of their own emotional state. A lot of people with BPD also have depression. Many are suicidal. Many have had a history of feeling attacked or uncared for’ they are almost hypersensitive to possible threats from others.

They react almost with a hair trigger — if they perceive they are being attacked, they go on the attack. People with BPD can be so preoccupied by their own sense of not being cared for and not being understood that they can become blind to the impact of their own behavior on others.

So how would you address increasing empathy in these conditions?

There are interesting and imaginative new approaches to treatment for empathy. Some are medications like oxytocin. Some are psychological treatments like Peter Fonagy’s work on mentalization therapy. I haven’t ever watched it done but the idea is to encourage the patient to stop and think about others’ thoughts and feelings. It’s particularly useful for BPD. When someone with that condition is mostly focusing on themselves, the therapist prompts them to take other people’s perspectives. And just through repetition and practice, people get better and better.

I don’t see how that would work with psychopaths.

People are doing some clinical approaches with psychopaths too, like getting them to meet their victims. That’s obviously got lots of traumatic risk attached to it [for the victim], but again, it’s an exercise in perspective-taking.

I think if we take seriously the idea that behavior is the result of the brain — that having low empathy [is] the result of the way the empathy circuit is functioning or has developed — it does raise moral questions. When someone is acting with low empathy, why do we judge them as bad and punish them? It does shift the locus of where [they should be treated] philosophically, from the criminal justice system to health care.

Don’t you think there are people who are actually evil, who know what they’re doing is wrong and harmful but choose to do it anyway?

I argue in the book that I don’t find the term evil very useful. Once you are down at zero degrees of empathy, all kinds of behavior become possible. I don’t find it scientifically useful to use that term. Empathy is a scientific term in a way that evil isn’t. You can try to localize it in the brain; you can look for which part of brain is activated. It’s normative behavior. Evil is kind of the opposite of good, I guess, but empathy, as we were talking earlier, is quantifiable and normal. You can measure it and look for it, whereas you don’t see evil in the brain.

It’s argued that humans were able to evolve cooperation and altruism only by having a way to detect and punish those who didn’t cooperate.

I could see an evolutionary benefit for both empathy and lack of empathy too. Low empathy allows you to act selfishly, which could be in your interest, but high empathy fosters social cohesion and it’s good for the individual to end up as part of a social network.

I speculate that maybe most people end up in the middle, which may be the optimal position. It’s good to have some empathy, so at the very least you avoid offending or inadvertently hurting someone, but too much empathy might mean never completing your own projects.

How does your cousin Sacha Baron Cohen, creator of Borat, rate on empathy? His work can really make you cringe, but he must be excellent at mind reading to do it.

First of all, he and I have a family agreement that we don’t talk about each other. I respect his work. I think that sometimes that kind of comedy can create what you called a “cringe reaction,” cringing with embarrassment, but that has a purpose.

Why does empathy seem especially lacking in the teen years?

It’s kind of interesting that parents comment on adolescence as being a low point in empathy. But there’s still quite a lot of maturation going on in the part of the brain that involves empathy during that period. There could also be hormonal factors, particularly in males with the increase in testosterone. That could change empathy levels.

I’m struck that if you look at the “terrible two’s,” kids who have tantrums when they don’t get their way, and teens, at one level it looks like very little development has gone on. There’s a transition at around age four to becoming able to apprehend that others have different perspectives. You would imagine that empathy would almost reach a peak in early childhood, but it seems to have a long protracted development.

It seems to me that the terrible twos and adolescence are both the most intense periods of brain development. Could that be why empathy is impaired then?

That’s really interesting. I think brain maturation is one thing and also just the experience of relationships. I think that empathy has to have an environment in which to work, and that environment is relationships. Making mistakes in relationships is all part of learning to empathize.

There was an interesting study I was part of. Women who took extra testosterone were given the ‘reading the mind in eyes test.’ [The test measures how well people can read others' emotions by looking at their eyes.] A dose of testosterone lowered scores on this test. It was one of the first demonstrations that changing testosterone levels affects your empathy.

If you’re taking an evolutionary approach, it might be very adaptive if you have to use aggression for self-defense. You’d be more effective if you didn’t have empathy getting in the way.

A U.S. doctor tried to treat autism by lowering testosterone levels, citing your work as justification, although he actually didn’t get the research right. He just lost his license because he was using a “chemical castration” drug on kids to do this.

We haven’t considering [lowering testosterone] as a treatment to study for autism. I’m not comfortable with it ethically in terms of side effects. They misquoted [our research], and cited it as evidence that there was elevated testosterone in autism when, in fact, we haven’t shown that. They presented it as if we’re endorsing it, which I’m certainly not.

See more of Healthland’s “Mind Reading” series.

Find this article at:

http://healthland.time.com/2011/05/30/mind-reading-psychologist-simon-baron-cohen-on-empathy-and-the-science-of-evil/

You can buy to book here:

See larger image The Science of Evil: On Empathy and the Origins of Cruelty (Hardcover) By (author) Simon Baron-Cohen List Price: $25.99 USD New From: $13.92 In Stock Used from: $9.88 In Stock

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Genetics in Borderline Personality Disorder

I was reading an article called “Social cognition in borderline personality disorder: evidence for disturbed recognition of the emotions, thoughts, and intentions of others” and noticed a line in the article that said this: “Thus, in addition to high heritability of BPD (Torgersen et al., 2008), these results argue that environmental factors (e.g., trauma) contribute to disturbed social cognition in BPD. In sum­mary, for the current study we expected PTSD to be a negative predictor of social cognition.” That intrigued me on two levels. One was the “high heritability” part, because often I see comments about BPD and how many people believe that it is mainly caused by childhood trauma (and/or invalidation). In WHINE I state this: As I said earlier, one of the causes of BPD is the “invalidating environment.” Now, it could be that it is not an actual “cause” (and that all the real causes of BPD are biological), but more a reinforcer of BPD. So, the second part of the article that intrigued me was the idea that “we expected PTSD to be a negative predictor of social cognition” – and the discussion and methodology of comorbid PTSD with BPD. What they found was that people with BPD (with or without comorbid PTSD) are less able to understand the intent, thoughts and motivations of social interactions in others – in other words, people with BPD can’t mentalize as well as controls. They also found that this lack of ability is more marked in people with BPD who also have comorbid PTSD. The fact that they mention comorbid PTSD at all is something of a revelation – or perhaps should be to us nons. Many people come to support lists and do research on the Internet and begin their “introduction” of their BPD person with a long list of childhood traumas that explains why the person has BPD. This current research would indicate that PTSD and BPD are clearly two separate disorders and that, while PTSD is a contributor to poorer functioning that BPD alone, BPD is in itself a highly inheritable disorder and biological in nature, yet “reinforced” or made more severe (especially in a social functioning sense) when PTSD is present.

Anyway, this research led me to another scientific study called “Familial Resemblance of Borderline Personality Disorder Features: Genetic or Cultural Transmission?” In which the researchers studied twins, siblings and parents of borderlines to determine the genetic underpinning of BPD or whether the environment and/or cultural influences could have more of an influence on the development of BPD. They found this: “In the present study an extended twin-family design was applied to self-report data of twins (N = 5,017) and their siblings (N = 1,266), parents (N = 3,064) and spouses (N = 939) from 4,015 families, to estimate the effects of additive and non-additive genetic and environmental factors, cultural transmission and non-random mating on individual differences in borderline personality features. Results showed that resemblance among biological relatives could completely be attributed to genetic effects.” and this: “There was no effect of cultural transmission from parents to offspring.”

Recently, in the ATSTP group, we have been discussing the idea that shame/honor-based cultures  and whether that environment could be explanatory in some sense of the development of BPD. It appears (at least based on this 2009 study) that the development and transmission of BPD is NOT cultural. It is essentially genetic (mainly “additive”, meaning it is more than one gene involved) and the environment has an effect, yet cultural transmission was not apparent.

They do go on to say this: “Gene by environment interaction implies that genes determine the degree to which an individual is sensitive to an environment. In the presence of gene-environment interaction, individuals with a ‘sensitive’ genotype will be at greater risk of developing BPD if an undesirable environment is present, than individuals with an ‘insensitive’ genotype.” So, basically, although this interaction has not been fully studied, it appears that some sort of “sensitive” genotype is required to develop BPD.

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Brain imaging gives new insight into mental disorders

(Media-Newswire.com) – HOUSTON — ( August 25, 2010 ) — A new kind of psychiatry built on objective measures derived from functional magnetic resonance imaging ( or fMRI ) of the brain performed while patients play economic games could provide new insight into the diagnosis and, eventually, treatment of mental disorders, said researchers from Baylor College of Medicine in a review in the current issue of the journal Neuron.

New tools, new field
These new tools will not only help produce new brain “signatures” associated with disorders such as autism, schizophrenia and borderline personality, they will also help identify the nature of normal variation in human decision making and the brain, said Dr. P. Read Montague, professor of neuroscience and director of the Computational Psychiatry Unit at BCM, and Dr. Kenneth T. Kishida, a postdoctoral fellow in the area.

Montague is a pioneer in a discipline that uses powerful fMRI machines to measure how blood flows in the brain while individuals play economic games that always involve choice and sometimes require cooperation between participants – a growing paradigm that has come to be known as neuroeconomics. The areas of greatest blood flow reveal what parts of the brain are involved during the decision-making process.

The two, along with Dr. Brooks King-Casas, assistant professor of neuroscience at BCM, describe a number of studies involving people with and without mental disorders in a review of the beginning of a new field – computational psychiatry.

Identifying disorders, defining “normal”
In a crucial prior study, King-Casas and others at BCM identified a characteristic fMRI “signal” that distinguished borderline personality disorder – a disorder that is extremely hard to diagnose – from psychologically healthy controls.

Not only do Montague and his colleagues seek to build a more concrete or objective method of diagnosis for mental disorders, they also seek to determine the range of what is considered healthy or “normal”.

“What is the nature of normal variation in these games,” said Kishida. “Can this help us measure the difference between what is considered healthy and what is pathologic?”

Augmenting assessment
Currently, most psychiatric diagnoses are descriptive, based on a cluster of symptoms recognized by professionals and codified in a standard guide called the Diagnostic and Statistical Manual of Mental Disorders. ( It is now known as the DSM-IV, and the DSM-V is scheduled for release in three years. )

Montague said their aim is not to replace psychiatrists or psychologists but “to augment their way of assessing people.”

Once scientists identify the brain signals associated with a particular pathology and the areas or tissues involved, they can then start to look for the genes associated with those patterns, said Montague and Kishida. That will involve scanning the brains of thousands of people, both those who are healthy and those with known pathologies.

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Anti-depressants and Depression

I believe that it has. Why? Well, there are a number of reasons that depression is a catch-all diagnosis. One certainly is the influence of the pharmaceutical industry given that billions of dollars are spent on anti-depressants each year. Also, doctors who are not mental health professionals (like GP’s) are prescribing anti-depressants if their patients are “depressed”.

Unfortunately, sometimes depression is not accurate. Many times when people say “I’m feeling depressed” they are really expressing that they are feeling emotional pain. Sometimes emotional pain is normal, sometimes a great deal of emotional pain is not normal and becomes problematic. When someone is feeling too much emotionally, it is not depression.

Depression is usually a problem when someone is feeling a strong lack of emotions – causing a lack of interest in the usual activities (including sex) that once gave us pleasure. Although many configurations of “depression” exist (because it is a non-specific term nowadays), the configuration in which one lacks emotions is alexythimia, although if one lives without pleasure it’s called anhedonia. I suspect that most people, when they describe being “depressed” are really describing a combination of anhedonia (where they can’t enjoy anything anymore) and social anxiety.

As I said above, another configuration that is referred to as “depression” is when the emotional pain becomes too overwhelming. In this case the person is feeling too much and would possibly beg for anhedonia because, while the pleasure would not be present, at least the pain would go away. I think that BPD probably involves more of this kind of “depression” than other disorders. The constant emotional pain leads people to doing anything to stop it (thus, this site’s name), including substance abuse, sexual promiscuity, risk-taking, self-injury and other seemingly self-defeating behaviors.

How can this be explained? How can someone be in such emotional pain all the time? One explanation comes from the study of u-opiods in the brain. A recent study by Stanley and Siever showed that people with BPD have too few u-opiods (the precursor for natural pain-killing neuro-chemicals) AND have over-active u-opiod receptors. This combination provides a baseline of pain and, when opiods are added, the brain feasts on these pain-killing substances with the over-active receptors. This is why some people with BPD can ingest large quantities of pain killers to seemingly little effect (or less effect than those without the disorder). I have heard people with BPD say they only feel “normal” while taking pain killers.

So, the question here is two-fold: First, are anti-depressants an appropriate treatment for emotional pain that is not really “depression”? And secondly, if not, what is? Low-dose pain-killers?

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Possible Genetic Causes Of Borderline Personality Disorder Identified

ScienceDaily (Dec. 20, 2008) — According to the National Institute of Mental Health, borderline personality disorder (BPD) is more common than schizophrenia or bipolar disorder and is estimated to affect 2 percent of the population. In a new study, a University of Missouri researcher and Dutch team of research collaborators found that genetic material on chromosome nine was linked to BPD features, a disorder characterized by pervasive instability in moods, interpersonal relationships, self-image and behavior, and can lead to suicidal behavior, substance abuse and failed relationships.

“The results of this study hopefully will bring researchers closer to determining the genetic causes of BPD and may have important implications for treatment programs in the future,” said Timothy Trull, professor of psychology in the MU College of Arts and Science. “Localizing and identifying the genes that influence the development of BPD will not only be important for scientific purposes, but will also have clinical implications.”

In an ongoing study of the health and lifestyles of families with twins in the Netherlands, Trull and colleagues examined 711 pairs of siblings and 561 parents to identify the location of genetic traits that influences the manifestation of BPD. The researchers conducted a genetic linkage analysis of the families and identified chromosomal regions that could contain genes that influence the development of BPD. Trull found the strongest evidence for a genetic influence on BPD features on chromosome nine.

In a previous study, Trull and research colleagues examined data from 5,496 twins in the Netherlands, Belgium and Australia to assess the extent of genetic influence on the manifestation of BPD features. The research team found that 42 percent of variation in BPD features was attributable to genetic influences and 58 percent was attributable to environmental influences, and this was consistent across the three countries. In addition, Trull and colleagues found that there was no significant difference in heritability rates between men and women, and that young adults displayed more BPD features then older adults.

“We were able to provide precise estimates of the genetic influence on BPD features, test for differences between the sexes, and determine if our estimates were consistent across three different countries,” Trull said. “Our results suggest that genetic factors play a major role in individual differences of borderline personality disorder features in Western society.”

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Experts Argue That Borderline Personality Disorder Should Be Shifted to Axis I

Thursday October 16, 2008

In a recent paper published in Biological Psychiatry, Dr. Antonia New and her colleagues at the Mount Sinai School of Medicine and Bronx VA Medical Center argue the case for shifting borderline personality disorder (BPD) from Axis I to Axis II of the Diagnostic and Statistical Manual of Mental Disorders (DSM).In the most current, fourth edition of the DSM, BPD is diagnosed on Axis II, which is reserved for “longstanding disorders,” such as personality disorders. In their paper, Dr. New and her colleagues argue that research has not supported the distinction between BPD and Axis I disorders, and that moving BPD to Axis I will spur new research on this serious condition.

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Emotion-Regulating Circuit Weakened In Borderline Personality Disorder

Differences in the working tissue of the brain, called grey matter, have been linked to impaired functioning of an emotion-regulating circuit in patients with borderline personality disorder (BPD). People with BPD had excess grey matter in a fear hub deep in the brain, which over-activated when they viewed scary faces. By contrast, the hub’s regulator near the front of the brain was deficient in grey matter and underactive, effectively taking the brakes off a runaway fear response, suggest researchers supported in part by NIMH.

The imaging studies are the first to link structural brain differences with functional impairment in the same sample of BPD patients. Similar changes in the same circuit have been implicated in mood and anxiety disorders, hinting that BPD might share common mechanisms with mental illnesses that have traditionally been viewed through the lens of biology.

Michael Minzenberg, M.D., of the University of California, Davis, and NIMH grantees Antonia S. New, M.D., and Larry J. Siever, M.D., of Mount Sinai School of Medicine, and colleagues, reported on their magnetic resonance imaging (MRI) findings in the July, 2008 issue of the Journal of Psychiatric Research Their functional imaging findings were reported in the August 2007 issue of Psychiatric Research Neuroimaging.

Accounting for up to 20 percent of psychiatric hospitalizations,4 BPD affects up to 1.4 percent of adults in a year. It is characterized by intense bouts of anger, depression, and anxiety that may last only hours, often in response to perceived rejection. People with this difficult to treat disorder typically experience tumultuous work and family life and may engage in risky, impulsive behaviors. Cutting, burning and other forms of self-harm are common. The completed suicide rate in BPD approaches 10%, and at least 75% of afflicted individuals attempt suicide at least once.

Previous findings of lower-than-normal grey matter matter – neurons and their connections – in the regulator hub, called the anterior cingulate cortex (ACC), hinted that this might affect the way the brain works in BPD.

To find out, the researchers first used functional magnetic resonance imaging (fMRI), to compare responses of 12 adult BPD patients with those of 12 healthy controls to pictures of faces with fearful, angry and neutral expressions. In response to fearful faces, the amygdala, the fear hub, showed exaggerated activity in the BPD patients, while the ACC was relatively underactive. Since ACC activity would normally increase to dampen an overactive amygdala, this suggested weak regulation of emotion in the circuit.

Suspecting that this functional impairment mirrors structural differences — as has been found in depression — the researchers next used anatomical MRI to compare grey matter in the same patients and healthy controls. Consistent with the fMRI results and the earlier findings, grey matter density was increased in parts of the amygdala and decreased in parts of the ACC, in BPD patients relative to controls. This suggested an abnormality in the number or architecture of neurons in these key components of the emotion-regulating circuit, which other evidence links to impaired functioning of the serotonin chemical messenger system.

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Science, an extraordinarily selective and highly prestigious publication,
includes a report, “The Rupture and Repair of Cooperation in Borderline
Personality Disorder,” by Brooks King-Casas and five collaborators
(including Peter Fonagy) in its August 8th issue. The editors of Science
felt this innovative research was of such potential importance that they
provided almost two full of Science’s limited pages for a commentary, “Trust
Me on This. Borderline personality disorder is associated with abnormal
activity in a brain region associated with monitoring trust in
relationships,” by Andreas Meyer-Lindenberg.

The Brooks King-Casas, et al paper in Science is another indicator of
innovative, significant research with a high potential for traction that can
come from collaborations between an investigator with leading edge methods
and borderline pd investigators, and a reminder of the importance of
reaching out to engage and to fund other investigators for ventures into
borderline pd research. Such engagements and funding represent an important
route to gain more positive attention for borderline pd, to increase the
interest in research concerning the disorder, to open new pathways for
borderline pd research and possibly to grow the number of investigators for
an area of study for which new investigators are vital for maintaining even
a modicum of vigorous research activity.

Abstract of August 8th Science paper:

To sustain or repair cooperation during a social exchange, adaptive
creatures must understanding social gestures and the consequences when
shared expectations about fair exchange are violated by accident or intent.

We recruited 55 individuals afflicted with borderline personality disorder
(BPD) to play a multiround economic exchange game with healthy partners.
Behaviorally, individuals with BPD showed a profound incapacity to maintain
cooperation, and were impaired in their ability to repair broken cooperation
on the basis of a quantitative measures of coaxing. Neurally, activity in
the anterior insula, a region known to respond to norm violations across
affective, interoceptive, economic, and social dimensions, strongly
differentiated healthy participants from individuals with BPD. Healthy
subjects showed a strong linear relation between anterior insula response
and both magnitude of monetary offer received from their partner (input) and
the amount of money repaid to their partner (output). In stark contrast,
activity in the anterior insula of BPD participants was related only to the
magnitude of the repayment sent back to their partner (output), not to the
magnitude of offers received (input). These neural and behavioral data
suggest that norms used in perception of social gestures are pathologically
perturbed or missing altogether among individuals with BPD. This
game-theoretic approach to psychopathology may open doors to new ways of
characterizing and studying a range of mental illnesses.

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Obviously, there are many, many new people who have no idea who I am or what I’m about. There are a few members still hanging around who do remember me. There are a couple of people who seem to have a pretty dim view of what I have to offer – although I think that those people don’t know me very well and have interacted with me only cursorily. First, today, I’d like to outline my philosophy about BPD and Non-BPs to clear up some of the mis-statements and mis-perceptions.

• I do believe that BPD is a serious mental illness and not a case of a “behavioral disorder.” In other words, BPD is not merely a case of someone just behaving badly. I further believe that much of the core issue with someone with BPD is emotional and based on poor emotional regulation skills. The reaction to strong negative emotions (and other factors, like  shame and impulsiveness) cause the “poor behavior.” I put that in quotes because the behavior has a function and the function IMO is to make the BP feel better. A person (whether they have BP or not) CAN learn to behave differently in the face of strong negative emotions. It takes practice and requires the acquisition of emotional skills. However, I also believe that the emotional under-pinnings are not going to disappear, just because the person with BPD learns to behave more effectively. Emotionally, they are just more sensitive than other people – that is the way they are. In other words, I don’t believe that I have a “cure” for BPD, which was bandied about at WTO.
• I also believe that the only person that you can change in a relationship is yourself. It is my opinion that once you change your own approach to emotional situations, the person with whom you are having the relationship will react to the change in various ways. Sometimes they will have a fit. Sometimes they will appreciate the “new you.” And sometimes a complex combination of emotions will arise. My “methods” are a combination of emotional understanding (of your own emotions and of theirs), emotional validation (which is complex in itself), positive reinforcement and “inserting your (the Non’s) feelings” into the conversation. There are some other skills and sub-skills, but that’s a quick synopsis. IMO this complex combination of skills (which also require practice) will improve the relationship and make sure that you don’t “walk on eggshells” around the other person. Boundaries can help – however, boundaries are a subject unto themselves, and I find that most people don’t know what boundaries are and how to apply them properly.
• There was some argument at WTO that my motives were suspect, because I am trying to make some money on what I have learned and practiced thus far. I think the operative word here is trying, because I don’t really make enough money to even operate this website at a break-even level. No, I’ve not made much money at all as a “professional Non-BP” (if that’s what I am). What I have been able to do is have an impact on the lives of many people. That is pretty satisfying in itself, and I will not pretend that I wouldn’t like to do it full-time. I certainly enjoy interacting with others in my situation and exchanging advice, strategies, knowledge, etc. more than my “day-job.” But it will be a long time (and probably never) before I will be able to do that. Besides, most of my support activity and knowledge-sharing I do for free – either here on in my Google Group. There’s no charge for participating in that group or to read these posts. At this point, any money I do make just contributes to the cost of operating this website.
• I don’t think that BPs have to be “let off the hook” and that they have no responsibility when it comes to a relationship. I also don’t think that you, as a Non-BP, have to forgo your feelings to live alongside a person with BPD. Both of those ideas were suggested at WTO. Neither is true. I think everyone in a relationship will have emotions, reactions, expectations, etc. Everyone is allowed to have each of these. Everyone has certain responsibilities in a relationship as well. What I DO advocate is looking at the function behind behavior and understanding the dynamic that exists. Many times I’ve seen people suggest that my methods give the BP “undo advantage” in a relationship. Huh? I thought this was a “loved one?” I don’t think that “love is a battlefield.” It’s not us-agains- them. That is just more black-and-white thinking on the part of the Non. If you’re going through a bloody divorce with someone with BPD, I can certainly understand where this might come into play, but, as I have said, my methods are about “living with and loving” someone with BPD. There is responsibility on both sides of the fence. It takes a certain environment IMO to make sure that responsibility is acknowledged – and that environment has to be one that is validating, otherwise you’re going to be caught in a shame hurricane. Nothing will get accomplished.
• Finally, I believe that effective emotional skills are helpful for anyone in any relationship. Anger, sadness, spite, resentment, blame, etc., etc. lead to a corrosive environment within any relationship. My “methods” attempt to reverse some of the corrosiveness and build stronger, healthier emotional relationships. You may not agree with my methods, which is fine. Personally, I’ve had to try everything to find anything that worked.

I guess it’s better to be talked about a little, whether it is positive or negative, than to be ignored. Thanks to a group member of mine who notified me of the discussion and who defended me (you know who you are).

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Here’s some information on  Amitriptyline studies:

Amitriptyline (Antidepressant Tricyclic)

Soloff PH, George A, Nathan RS, Schulz PM, Perel JM.
1987 Psychopharmacol Bull.23 – Behavioral dyscontrol in borderline patients treated with amitriptyline.
Amitriptyline was associated with a paradoxical behavioral toxicity in patients with BPD, increasing suicidal ideation, paranoid thinking, and assaultiveness significantly more than among placebo nonresponders

Amitriptyline (Antidepressant Tricyclic) / Haloperidol (neuroleptic)
Soloff PH, George A, Nathan S, Schulz PM,… – Western Psychiatric Institute and Clinic, University of Pittsburgh, Pennsylvania.
J Clin Psychopharmacol. 1989 Aug – Amitriptyline versus haloperidol in borderline: final outcomes and predictors of response.
The authors report the final results of a 4-year study of amitriptyline and haloperidol in 90 symptomatic borderline inpatients. Haloperidol produced significant improvement over placebo in global functioning, depression, hostility, schizotypal symptoms, and impulsive behavior.
Significant effects of amitriptyline were generally limited to measures of depression.

Amitriptyline (Antidepressant Tricyclic) / Haloperidol (neuroleptic)
Arch Gen Psychiatry 1986 Jul – Progress in pharmacotherapy of borderline disorders. A double-blind study of amitriptyline, haloperidol, and placebo.
In symptomatic patients with borderline disorder, we conducted a double-blind, placebo-controlled trial of haloperidol and amitriptyline hydrochloride to test the differential efficacy of medication against the affective and schizotypal symptoms that characterize the disorder.
Haloperidol was superior to both amitriptyline and placebo on a composite measure of overall symptom severity, with no difference between amitriptyline and placebo.
Haloperidol produced significant improvement on a broad spectrum of symptom patterns, including depression, anxiety, hostility, paranoid ideation, and psychoticism. In contrast, amitriptyline was minimally effective, with small gains limited to some areas of depressive content.

Here’s more on that abstract about amitryptiline (Elavil):

Paradoxical effects of amitriptyline on borderline patients

PH Soloff, A George, RS Nathan, PM Schulz and JM Perel

A paradoxical increase in suicide threats, paranoid ideation, and demanding and assaultive behavior occurred among 15 borderline inpatients receiving amitriptyline in a double-blind study. This pattern differed significantly from that of 14 nonresponding patients receiving placebo.

As you can see, if dyscontrol and and increase in  “suicide threats, paranoid ideation, and demanding and assaultive behavior” occurs in people with BPD on Amitriptyline – it’s probably best to stay away from it. Of course, I’m not a doctor. Obviously, you should consult one before stopping meds or beginning new ones.

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I found another reference to sleep issues on the Internet. According to this site, people with BPD have “significant abnormalities in REM sleep with more rapid onset and more intense REM sleep.” I’ve noticed that my wife has trouble falling asleep with major insomnia and has trouble getting up in the morning. If your BP has a job that he/she has to be at early in the morning, it might be time to find a new job.

Here is a reference I found on Paul J. Markovitz M.D., Ph.D.’s CV:

Markovitz, PJ, Comorbidity of migraines, PMS, IBS, fibromyalgia, neurodermatitis, and sleep apnea in borderline personality disorder: a possible serotonin link. Presented at the World Health Organization meeting on Personality Disorders, Cambridge, MA, September 1993.

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No celebrity has come out and announced that they have the disorder. While several celebrities have said they have bipolar disorder (just search on the Internet and you’ll see), no celebrity has announced they have BPD. Why? Probably because of the stigma (see below). There are certainly candidates for the disorder, but no poster child yet.

Many people believe that BPD is just a case of the person behaving badly. Non-BPs are definitely guilty of this in spades. The behaviors associated with the disorder – including drug abuse, lying and manipulation – lead many people, including family members and therapists, to believe that the disorder begins and ends with behavior. While behavioral therapies seem to be the most effective in treating the disorder, emotional dysregulation and cognitive disortions play a big role and shouldn’t be ignored. A person with BPD is not just someone behaving badly. They are trying to adapt to the large amount of emotional pain that they feel. Sometimes these adpatations will take the form of dangerous and distructive behavior, but that behavior is not about anyone other than themselves – in other words the behavior is not about you (the Non-BP).

When Hope is Not Enough
Get the Non-BPD book that is designed for
staying and working on the relationship

Bipolar is an Axis I disorder and BPD is an Axis II disorder. This really must change. Historically, BPD has been considered a “personality” disorder. People see it as a character flaw (even some of the sufferers). It is not a character flaw – it is a serious emotional and mental illness that should be treated as such. There are biological components to BPD just as there are biological components to bipolar disorder. It’s time to get rid of the Axis II classification of BPD and treat it like bipolar disorder.

There is a huge stigma surrounding BPD. If you do a search on the Internet and read Non-BP stories, most are in the vein of “I’m glad I got rid of my borderline wife.” There are several Non-BP books that are also in this vein. There is little worse in the mind of the public than someone having BPD. It’s time to remove the stigma. I hope that deeming May as BPD awareness month will help to increase awareness and remove the stigma.

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The effect of genes on the development of BPD is likely substantial. The effect of common family environment may be close to zero.

While the study doesn’t conclude that BPD is 100% inherited, it does point to certain genetic factors in the BPD adaptive behaviors (or maladaptive).

The main point of posting this is to chip away at the myth that BPD and other personality disorders are all the “fault” of parenting or abusive environments. One of the big problems that I have seen in the social, psychological and medical community is that when a child is identified as borderline, the parents immediately come under suspicion as being abusive or neglectful. This can cause more consternation and confusion on the part of the parents who are already dealing with a serious mental illness and the issues that come with it.

There is a common myth concerning BPD. That myth is that BPD is completely and only caused by abusive environments. Invalidating environments can be a contributing cause – but these invalidating environments do not have to be abusive. If a certain child is emotionally unstable, sometimes the parents’ reaction is “cut it out” or “get over it”. The problem with this approach is that the child feels how they feel regardless of their adpative abilities (or lack thereof). In other words, the child may feel scared or angry even if there is no external reason to feel that way. These feelings (or the inability to control them) CAN be genetic – it might be that that is just the way that they ARE.

That being said, BPD is not a sure thing or a life sentence. The sufferer can learn skills to adpat to their emotional states. Their families can also learn these skills and, if they do, they can stop contributing (even unknowingly) to the borderlines problems.

It is saddening that personality disorders (particularly Borderline and Schizotypal) are classified as Axis II disorders when other disorders (like Bipolar and Schizophernia) are Axis I. Why does it matter? It matters because of access to mental health care is restricted due to insurance coverage limitations.

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Version A) they are just born that way. THEY are not even sure of what they are ashamed of. They carry around three core beliefs: “The world is dangerous and malevolent”, “I am powerless and vulnerable” and “I am inherently unacceptable.” But they don’t know WHY – they have just always been that way. The only reason that I can gather is that they have labile emotions and they lead to an unstable sense of self. That instability is what they are ashamed of (and scared anyone and everyone will know). It’s like a nightmare in which you’ve pissed your pants and you hope to god no one will notice. That’s the shame component as far as I can tell. It’s not about anyone other than themselves.

Version B) Same as version A but caused by the environment.

Oh and version C – mix and match versions A & B.

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I find it astounding that 72% answered “less than 16 years old”.

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Genetic studies of monozygotic and dizygotic twins suggest that there may be genetic factors for these dimensions of emotional reactivity and impulsive aggression, while there does not appear to be a heritability for BPD as a category. Family members of BPD patients are more likely to demonstrate affective instability or impulsivity, although not necessarily both. Impulsivity and aggression seem to be heritable in studies of normal twins as well. It is noteworthy that in the studies of prolactin responses to fenfluramine, blunted prolactin response to fenfluramine in a patient is a better predictor of impulsivity and aggression in their relatives than was impulsive aggression as a behavior in itself in the patient. These results would suggest that what is inherited is not the behavior, but an alteration in the serotonergic system that may at times be expressed in a propensity to impulsive aggression.

So, according to this article, it’s not BPD that’s inherited, only the traits of BPD (impulsive aggresion). On a personal note, I have twins (dizygotic or fraternal) and one seems to have the emotionality and impulse control issues, the other does not.http://www.mhsanctuary.com/borderline/siever.htm

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We believe that this hyper excitability in BPD patients, particularly in brain regions thought to be involved in generating emotions, is likely to put this patient group at high risk for experiencing episodes of abnormally intense and inappropriate negative emotions characteristic of ED. In support of our hypothesis, we also found that the level of amygdala activation to the Fearful, and Neutral faces in BPD patients is significantly correlated with diagnostic measures of emotional lability.

So, what does this mean? If you “go calm” or “neutral” on the BP in your life, they will not understand it – their brain sees “neutral” as threatening.

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