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A short article from About.com regarding an Article in Biological Psychiatry about moving BPD to Axis I:
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.
An article about emotional regulation in BPD….
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.
Often I see in the support groups on the Internet (especially the “Welcome to Oz” or WTO groups), people providing the “3 C’s” of understanding your role as a Non-BP. I’ve seen it quoted on BPD support websites too. These “3 C’s” go as follows:
- I didn’t cause it
- I can’t control it
- I can’t cure it
While these statements are generally true, I’d like to take some time to analyze these statements and add a fourth “C.” I’d also like to tell you what you CAN do – rather than what you didn’t or can’t do.
These statements help take the onus off the Non-BP for any responsibility for their loved one’s disorder. I can understand that. In part, they are about blame or, better, non-blame. I’ve seen many people say “when I came to terms with those ‘3 C’s’ I was free from FOG!” (which is fear, obligation and guilt, for those of you who don’t know). I want to write something about FOG specifically, but haven’t had the time.
OK, now let’s look at each of these statements and see how they fit into my way of thinking about being a Non-BP.
I didn’t cause it
Actually, this statement is liberating, especially for parents of BPs. I think that many parents carry around a lot of guilt that they DID cause their child’s disorder. Even psychologist and therapists often blame the disorder on the parents. However, there are growing studies that suggest that there are many biological causes for BPD. In the case of Marsha Linehan, she provides a “biosocial” model, in which each element (biological and social) are required to cause BPD. The environmental part of that analysis is the “invalidating environment.” So, while you (either as a parent or spouse) didn’t cause the disorder, you may have inadvertently contributed to the disorder’s severity. By reacting to a BP in an emotionally invalidating manner, the disorder can get worse. That is why I spend over 30 pages in WHINE discussing emotional validation as a tool for healing. Of course, a parent might say “Well, I have other children. I’ve treated them the exact same way. Why don’t they all have BPD?” Which again is where the biological element enters. My suggestion for parents is to read the article referenced below.
I can’t control it
Why would you want to? No one can completely control another individual. Even parents can’t completely control the actions and behaviors of their own children. No, the only behavior (which is BTW what Non-BPs are so confused and angry about) you can control is your own. That is why I have made several statements clarifying boundaries. Boundaries can’t be used to control other people’s behavior. If you try and imposed rules on another person’s behavior, you get resentment, rebellion and (in the case of BPD) a statement: “You’re trying to control me!” How many times have you heard THAT in your interactions with a BP? I’ve heard it a bunch.
I can’t cure it
Again, this statement is true. Only the BP him/herself can “cure” the disorder (usually with the help of a qualified and knowledgeable professional). It is important that you re-read that statement – you cannot make your loved one “all better.” You can’t save him or her – especially from his or herself. What CAN you do then? You can contribute to an easing of the conditions under which the BPD behavior is severe. You can re-frame your relationship with the BP in such a way that the emotional invalidation that they have learned to expect is gone. You can encourage effective behavior and practice effective behavior yourself. How? I explain this in detail in WHINE – which is why I called it a “how-to” book.
Now, I think I need to contribute a fourth “C” to the mix. I didn’t make this “C” up. In fact I found it here, on A. J. Mahri’s “BPD from the inside out” page about a mother speaking out about the illness. Please read that page! It really helps define the feelings and confusion of a mother who needed to know she “didn’t cause it.” She offers a fourth “C” which is:
All I can do is cope with it.
Someone forwarded this information to me this morning….
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.
 Apparently, someone over at Welcome to Oz (WTO) Internet list posted a message asking about me and what I am all about concerning BPD and Non-BPs. This lead to a huge spike in traffic with my average number of accesses basically doubling over the weekend. I’m still a member of WTO, so I decided to login and take a look at what people are saying about me over there. I haven’t posted in years and haven’t logged in in months.
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).
For some reason, I get a lot of searches on this blog about Amitriptyline and BPD. I posted a note on Amitriptyline and Xanax and their interaction with BPD. I still get a lot of hits on that brief snippet, even though I wrote it back in 2006. I also spelled Amitriptyline with two “l’s” as amitryptilline (Elavil). I’m not sure which is the correct spelling, but I’ll put them both here so people searching can get hits on this post.
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.
 One of the physical aspects of BPD is problems with sleep. People with BPD are likely to have trouble going to sleep and trouble getting up in the morning. One of the reasons is the “ruminating” aspect of BPD. Another seems to be that their brain chemistry is configured in such a way to utilize serotonin ineffectively. Many people with BPD will require sleep medications and sometimes will take these medications in large doses. This inability to sleep and awake punctually can also contribute to getting fired from jobs. If a BP can’t get up on time and make it on time to a job, they might get fired. Losing a job can contribute to shame. Jobs that have a lot of “down time” (time in which nothing is going on, like lulls in retail positions) can cause more ruminating and may lead to conflict between someone with BPD and their co-workers or superiors.
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.
I am often asked why Borderline Personality Disorder is not as recognized and as accepted as bipolar disorder . I think there are four main reasons:
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 EnoughGet 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.
In this study, researchers posit that traits associated with BPD are inherited (impulsivity and emotional regulation). Here is a quote from the abstract:
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.
I recently saw a thread in which borderlines were discussing their “hypersensitivity” to certain sensory stimulation.
If you know my story, you know that one of my daughters has dysfunctional emotional reactions. I like to think of that as pre-BPD. I hope that the actual onset of full BPD can be avoided. One of the things that has started happening with her more and more is she has developed a sensitivity to certain foods. She can’t eat certain foods and she finds certain smells offensive. The other day she found the milk smelled sour, even when it was not sour for everyone else in the family. I think this hypersensitivity thing has some merit.
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