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Article on fMRI and BPD… I had the pleasure of meeting Dr. Montague last year. Intersting guy…
Brain imaging gives new insight into mental disorders
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.
(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.
 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?
From Science Daily:
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.”
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.
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.
First of all, BPD is not a pleasant experience. Being awash with negative emotions all the time is quite painful and unpleasant. Most people with BPD know that they are “not normal” in some way and don’t like feeling like they do. No one would as it is very painful.
A person with BPD is characterized by having a diminished ability to regulate one’s emotions during the interactions with other people. This means that someone with BPD will likely react much more emotionally to a given situation than someone without BPD. People with BPD are likely to get angry and, at times, fly into a rage of seemingly trivial events and interactions. They also have a tendency to personalize external events. In other words, the person suffering from BPD will believe that other people’s behavior and comments are “about them”, sometimes interpreting veiled criticism or judgment of their behavior when the evidence shows that there is none. The person with BPD is also likely to be seemingly obsessed with blame and fault-finding. You will likely hear a person with BPD say, “It’s not my fault!” or “I did nothing wrong!” These comments and fault-finding behaviors are a consequence of sensitivity to judgment and rejection.
Everyone has both an in-born and learned capacity to regulate his or her emotions. I will discuss what factors contribute to these capacities and how you, as a loved one of someone with BPD, can cope with the problem. As stated earlier, emotions play a vital role in our ability to survive in a sometimes threatening environment. They are “mind reflexes” that protect and inform the mind of the state of the body and the body’s assessment of the immediate surroundings. Unfortunately, as with BPD, the messages that are sent are sometimes misaligned with the actual environment.
The ancient Hindu text characterizes this “misperception” of reality in the following manner: “A rope may be momentarily perceived as a snake before ignorance is lifted.” [Sankaras Aparoksanubhuti, verse 44] The importance of this “ignorance” is that during the time the rope is perceived as a snake, your emotions react almost completely automatically. (I say “almost” because if you have been taught to love snakes and not to fear them, you will not have a fear reaction even if you misperceive the rope as a snake). You feel fear, it is real and you jump away. Your body reacts as well. When I say “feel fear” I really mean it. Your heart rate increases, the capillaries in your extremities contract to save blood for vital organs, adrenaline is released to your blood stream. Your fear is real and felt directly. However, it is based on a misperception with reality. When you see that it is actually a rope, you might feel foolish or you might, if you had BPD, still try and convince everyone else and yourself it is really a snake or it is a rope that can harm you. The reason is that your feelings are so immediate and seem so “true” than you have to make “reality” match your feelings, rather than the other way around. When an emotional reaction conflicts with the state of the environment for whatever reason, it is said to be a “misaligned” emotional reaction.
The core problem with BPD is poor emotional regulation. However, that particular problem can cause other symptoms to arise as the person with BPD becomes emotionally dysregulated. This term emotionally dysregulated (or just dysregulated) is used to denote the state in which a person with BPD is overcome with powerful and, at many times, misaligned emotional reactions. Remember that emotions don’t arise on their own; they are based on cues or triggers from the environment and compared by our “emotional immune system” to the meaning of the cue. For a person with BPD, the meaning can be wrong or, as is more often the case, the sensitivity to emotional cues is greatly heightened.
An example is a heat-sensing system that helps to detect and suppress fires. Sometimes companies will install heat-sensing equipment in addition to smoke detectors so that they can protect assets that need a certain temperature to operate (e.g. computer equipment which might cease working at a high temperature). The setting at which an alarm goes off might be 80 degrees Fahrenheit. In the case of someone with BPD, the setting (or “tolerance” as it is called in the control community) is naturally set much lower, at say, 50 degrees Fahrenheit. That means that the alarm will be raised much more often and lead to a reaction to the alarm. In other words, people with BPD will experience many, many (what you would consider) false alarms. However, these false alarms seem completely real to them, because their tolerance for emotional triggers is set very low.
I often peruse the web for articles and posts about dealing with people with Borderline Personality Disorder and what I usually find is incorrect and misguided. I recently stumbled upon a post that can be found here:
http://www.helium.com/tm/339437/individuals-suffering-borderline-personality
In which the author gives some insight and advice about “dealing with” someone with Borderline Personality Disorder. I’d like to look at her advice by excerpting some of her text and then offer a little commentary.
First of all, she says this:
Individuals suffering from borderline personality disorder are very self-destructive and they have great difficulty forming any good relationships. A deep-seeded fear of abandonment is behind every wayward action and prolonged mood swing. It’s [sic] victims are mainly women who show frequent displays of inappropriate anger and who exhibit forms of self-mutilation. They also act on impulse, without regards to consequences and than [sic] hold others responsible for their actions. They are sexually permissive and may indulge in binge eating and drug abuse. Victims of this disorder may shop lift. Hell bent on harming themselves, they live with no discipline or boundary.
While this characterization is generally true, it suffers from what wikipedia calls “weasel words”. Basically, the words that are used slant the information toward being extremely judgmental. What I mean is the use of the words “great difficulty forming any good relationships,” “every wayward action and prolonged mood swing,” “show frequent displays of inappropriate anger,” and “they live with no discipline or boundary” all show us that the author is judgmental toward the sufferer. The idea of “prolonged mood swing” is incorrect as well, since the “moods” of a person with BPD generally last only hours. Also, the idea that “they are sexually permissive” MAY be true for some of the sufferers, but not for all. The idea that a “fear of abandonment is behind EVERY wayward action” is also incorrect. Much of the “actions” are motivated by pain relief and/or shame. Use of the words “no discipline” betrays the authors true feelings about people with the disorder and tells me she doesn’t understand the disorder very well (see below on “Tough Love”).
 When Hope is Not EnoughGet the Non-BPD book that has helped hundreds! If you have the disorder, give it to you loved ones! It will help. The author goes on to say:
Group therapy can resolve self-destructive behaviors. These individuals learn better from their peers because of their resistance to authority. Impulse behavior can be curtailed in this same setting.
Which is basically wrong. Group therapy does work (especially in the context of DBT), but not for the reasons that the author suggests. It is not a “resistance to authority” that drives the effectiveness of group therapy. Instead, seeing that one is not the only sufferer and having the ability to support one another normalizes the disorder. You are not just the broken, shameful person that you feel you are. Interestingly, many people with BPD will criticize others in the group and report that they are not as “crazy” as those people are.
The thing I have the most problem with is this:
Tough love may be needed from family members and loved ones before the person asks for assistance.
This statement is completely false and possibly harmful. Here is the text of a post of mine in the ATSTP group which addresses Tough Love:
Depending on the actual problem with your son(s) the idea of “tough love” might be the worst thing for him (them). While it seems to work for substance abuse, tough love can be an awful mixture for those with ERD-like issues. The problem comes down to the “invalidating environment” as Marsha Linehan puts it. Tough love will invalidate a person’s basic feelings and lead to shame and the feeling of “brokenness”. I have seen this first-hand with one of my daughter’s friends. This friend is 16 now and is a classic BPD/ERD case. She has been kicked out of several “lock down” facilities. Recently her mother sent her to a “tough love”/boot camp. It was a total disaster for the kid and for the family.
A better approach IMO, is emotional validation + a sense of personal responsibility. This combination is built through letting the person know that feelings are not wrong or right, they just ARE. The second half comes through building mastery over their behavior associated with feelings. Bad feelings just exist. This is important because often a person with such issues will use behaviors (like drug abuse or cutting or raging) to make the bad feelings go away as quickly as possible. They need to learn to tolerate the distress and behave in an effective manner. Once this new behavior/reaction to feelings is practiced, they can eventually build mastery over the behaviors. This works backward to help quell the feelings.
It seems that most parents believe that emotional validation = “giving in” (or agreeing with the child or “poor discipline” or whatever). This is NOT the case. It’s difficult for me to express this more firmly. Remember the word “emotional” is important. If you validate invalid behavior, you are enabling. It is important to separate in your mind the emotions (which are natural) from the behavior (which can be painful to all involved). If that separation can be communicated to the person with ERD, it can be worked with. It is difficult, but possible.
Unfortunately, tough love is not the answer.
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.
This is a link to site positing that adopted children are often mis-diagnosed with Borderline Personality Disorder (BPD). Sometimes, BPD is characterized by an “”inability to connect”" with parents. In the case of adopted persons, the initial invalidation of being “”rejected”" by one’s birth parents can be a life-long struggle. I have found that in Family Support groups close to 40% of the children diagnosed with BPD were adopted. However, there is another theory that has been overlooked by this author. That is that the birth parents of these children may have exposed them to biological impulsivity. If the mothers of the adopted children are impulsive – having sex and getting pregnant when it is not possible to keep a child – is it likely that the impulsivity has been passed down to the child? Meaning, the parents (who may have BPD tendencies, since they are often young and impulsive and engaging in unsafe behaviors themselves) may biologically pre-dispose those children to emotional dysregulation and BPD. It is impossible to know whether these children would develop BPD if they had stayed with their birth parents, but, going back to the biosocial model, they may have biological factors from their parents that are furthered by the initial rejection. This is just a theory and not based on scientific evidence at all. I would agree that, given my experience with families of diagnosed borderlines, a large portion of the children are adopted. Certainly, more study is needed. I would just suggest that perhaps the unsafe and impulsive behaviors of their birth parents might also play a role in their development of emotional dysregulation. It is not necessarily all the “”inability to connect”" with the adopted parents.http://borderlinebyproxy.blogspot.com/2006/04/bpd-adopted-important.html
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