Borderline Personality Disorder: From Brain to Mind

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Borderline Personality Disorder From Brain to
Mind

• B.Grosjean.MD.
• Harbor UCLA.Grand Round
• 2-7-2006.

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NMDA

• Psychotherapy

Glutamate
Pharmacotherapy
Attachment Theory
Education
PCP 5HT
Dissociation
PTSD
Neuroimaging

• Theory of mind

Learning theory
Psychoanalysis
Emotion
Psychopathology
Molecular biology

• Genetic

• Cognition

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Borderline Personality Disorder
Brain
Mind
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• Borderline Personality Disorder
• Epidemiology

• Prevalence
• 1-2 general population (USA).
• 71-73 women
• Up to 10 of psychiatric outpatients and 20 of
  inpatients.

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• Borderline Personality Disorder
• Etiopathology

• Genetic Disposition/ Temperament
• Pathology of early attachment
• neglect
• trauma
• chaotic-disorganized?
• HPA axis hypersensitivity
• Neurotransmitter Systems ?
• ?? NMDA receptors dysfunction??
• ??? Mirror neurons dysfunction???

Inpatient BPD 76 reported physical abuse
86 reported sexual abuse (26 w/o BPD)
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Borderline Personality Disorder Diagnosis

• Behavioral/ affect regulation/
• Cognition
• Perceptual Alteration

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Borderline Personality Disorder 1- Behavioral
Symptoms

• Poor affect regulation
• Poor impulse control
• Unstable relationships
• Risky behaviors (substance abuse etc)
• Suicidality, self harm

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Borderline Personality Disorder 2- Cognition

• Problems with
• Working memory
• Autobiographical memory
• Learning processes (reversal learning?)
• Mentalization.
• Executive functioning
• Tasks that require controlled attention
  processing
• Attentional network involved in conflict
  resolution and in the voluntary inhibition of
  thought and behavior.

Fonagy,Bateman 1995,2004 Posner 2002,Lezenweger
2004Fertuck 2005.
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Borderline Personality Disorder 3- Perceptual
alterations

• Impaired emotion recognition as revealed by the
  impaired ability to read and/or to interpret
  facial expressions of emotion Donegan 2003.
• Dissociation Zanarini et al 2001.

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Borderline Personality Disorder Neuroimaging

• Reduced hippocampal and amygdalar volumes.
  Driessen 2000Rush 2003 Terbatz van Elst 2003.
• Aberrant functioning in the cingulate cortex.
  Hazlett 2005 Milham et al 2005.
• FMRI of BPD patients listening to scripts
  describing abandonment events show dysfunction of
  medial and dorso-prefrontal cortex. Schmal 2003.
  
• Smaller corpus callosum in abused and or
  neglected children. Teicher 2003,2004

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Treatment ?
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• Borderline Personality Disorder
• Validated/Manualized Treatments

• Transference Focused Psychotherapy (TFP)
• Otto Kernberg. Object relation theory. 1967.
• Dialectic Behavioral Therapy (DBT)
• Marsha Linehan Deficit in self regulation.1994.
• Mentalization Based Treatment (MBT).
• Bateman, Fonagy. Deficit in mentalization
  processes. 2000.
• Medications can be an adjunction but are useless
  without psychotherapy.

75 meet criteria for remission after 6
years 60-75 after 20 y F/u no longer meet
criteria for BPD 9 completed suicide
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BRAIN
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• 100 billion neurons
• Each develops between 1,000 to 10,000 connections
  with other neurons

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Geography of the brain
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Right and Left

• Left Hemisphere
• Linear processing
• Linguistic
• Logical-syllogistic reasoning
• Literal
• brings cohesion (not coherence) to make sense
  (integration) needs communication with Right
  Hemisphere/corpus callosum.

• Right hemisphere
• (develop before left)
• Holistic
• non verbal, music
• visual
• Face recognition
• ambiguity
• empathy
• autobiographical memory integrated map of the body

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Corpus CallosumINTEGRATION

• largest white matter structure in the mammalian
  brain
• connects the left and right cerebral hemispheres.

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HippocampusPUZZLE ASSEMBLER.

• Essential role in the formation of new memories
  (episodic or autobiographical/ EXPLICIT)
• required for simple spatial memory tasks .

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AmygdalaEMOTIONAL BRAIN

• Key role in the emotions (fear pleasure).
• Key role in implicit, emotional memories
  interprets the emotional significance of the
  experience.

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Memory

• IMPLICIT
• Present at birth
• No sense of recollection present when memories
  recalled and encoded
• Includes behavioral, emotional, perceptual, and
  possibly bodily memory

• EXPLICIT
• gt 2 y/o
• Requires conscious attention
• Sense of recollection present when being recalled
• Includes semantic (factual) and episodic
  (autobiographical) memory
• Involves the hippocampus

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Anterior Cingulate CortexConflict monitoring

• Vital to cognitive functions, such as reward
  anticipation, decision-making, empathy, and
  emotion.
• Involved in a variety of autonomic functions (HR,
  BP)
• responsible for rendering new memories permanent.

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Pre-frontal cortex

• Body regulation
• Emotional regulation
• Attunement
• Response Flexibility
• Empathy
• Fear Extinction
• Intuition
• Morality
• Self-Knowing Awareness

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Medial Prefrontal Cortex

• Activated by observation of social interaction
• Activated during mentalization
• Activated with meditation, body exercises, prayer
• Size correlate with degree of meditation ?

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NEUROPLASTICITY
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NEUROPLASTICITY

• Development shapes the brain by altering the
  strength of synaptic connections within the
  brain.
• synapses can be strengthened, weakened or
  eliminated (pruning)
• new synapses can be formed in response to
  experience
• genetic information, toxic substance, and
  stressful or absent experience can lead to
  elimination of synapses.

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• Brain growth spurt in humans between the last 3
  months of pregnancy and extends into the first 3
  years of life.
• Major Pruning end around the end of puberty.
• Adult brain remains plastic during the entire
  life.

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Neurotransmission

• Serotonin impulsive aggression, working memory
  and inhibitory processes
• Dopamine emotional regulation, motivational
  systems, and cognitive perceptual phenomenon.

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Glutamate

• Primary excitatory neurotransmitter in the
  mammalian brain.
• Involved in many CNS mechanisms of plasticity
  including those contributing to learning and
  memory.

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N-methyl-D-aspartate subtype glutamate receptors
(NMDARs)

• Concentrated in the hippocampus, forebrain,
  amygdala, caudate, putamen and thalamus (rodents)
  
• NMDAR, can detect the coincidence of 2 events,
  so called associativity.

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NMDA Receptors
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NMDARs

• Hypofunctioning of the NMDAR, causes learning
  impairment, memory impairment (working memory)
  and dissociation.
• Overactivation of NMDA receptor via the glutamate
  site results in neurotoxicity and cell death.

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Mirror Neurons
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The Miracle ?
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Mirror Neurons

• A class of neurons that discharge not only when
  a monkey executes goal-related hand action, but
  also when observing other individuals executing
  similar actions.
• Gallese, Rizzolatti et al. 1996

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Mirror Neurons Empathy Einfühlung

• Iacoboni proposes that the human mirror neuron
  system, in concert with the limbic system, play a
  major role in the process of understanding the
  emotion and intention of other peopleand would
  be at the origin of empathy.
• To empathize, we need to invoke the
  representation of the actions associated with the
  emotions we are witnessing.

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Mirror Neurons Empathy Einfühlung

• fMRI study showed that same brain region are
  activated while observing an emotion or during
  the imitation of the emotional face expression
• These data suggest that we understand the
  feelings of others via a mechanism of action
  representation, so we build our empathic
  resonance in the experience of our acting body
  and the emotions associated with specific
  movements .
• Neural mechanisms of empathy in human a relay
  from neural systems for imitation in limbic area
  Carr, Iacoboni et al 2003

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MIND 1

• The mind develops as the genetically programmed
  maturation of the brain responding to ongoing
  experiences.
• D.Siegel. The Developing Mind 1999.

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MIND 2

• Development is about the creation of specific
  circuits, not merely the overall amount of
  synapses in the brain.
• The ways in which the circuits regulating
  emotional and social functioning develop is
  profoundly influenced by interpersonal experience
  beginning early in life.

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MIND 3

• Attachment researches indicate that good
  attachment relationship are likely to promote the
  development of integrative capacities of the
  brain in enabling the acquisition of emotional,
  cognitive and interpersonal abilities.

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MIND

• Siegel (2001) propose as the qualities that
  foster secure attachment
• Collaboration
• Reflective dialogue
• Repair
• Coherent narratives
• Emotional communication

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BETWEEN BRAIN AND MIND
Emotion
Mentalization
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Emotions
Facial expression are a crucial component of
human emotional and social behavior and are
believed to represent innate and automatic
behavior patterns Darwin 1872
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Emotions

• Emotional expression allow the rapid
  communication of information between individual.
• They can be viewed as reinforcers that modulate a
  particular behavior.

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Mentalization
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Mentalization

• Ability to read the expression on anothers face
  and know what this person is feeling.
• Ability to represent the mental states of others,
  i.e. their thoughts, desires, beliefs, intention
  and knowledge.

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What prevent acquisition of mentalization ?

• Genetic?
• Toxic environment ?
• Trauma
• Neglect
• Chaos

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The Challenge

• 906,000 children victims of abuse or neglect in
  2003. (1.24 of general population).
• Neglect 60 physical abuse19 sexual abuse 10
  emotional abuse 5 "other 17.
• Children ages birth to 3 years had the highest
  rates of victimization at 1.6 of the same age
  group. Girls were slightly more likely to be
  victims than boys.
• Child Maltreatment 2003 Summary of Key
  Findings National Clearinghouse on Child Abuse
  and Neglect Information 2005

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Bruised brains aching minds Developmental Effects
of Child Abuse and Neglect

• High levels of cortisol destroy synapses.
• Abuse, neglect and chronic states of
  misattunement lead to an overpruning of synapses
  (R OFC) leaving individuals with impaired ability
  to modulate and regulate emotion in response to
  stress.

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Bruised brains aching minds Developmental Effects
of Child Abuse and Neglect

• Overwhelmed hippocampus is unable to process
  explicit memory
• Implicit recollection w/o explicit processing
  maybe the source of flashback.

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• Maltreated children have multiple problems
• Isolation, hence fewer non parental model of
  emotional communication.
• Difficulties in recognition, expression and
  understanding of emotions (Camras et al 1996).
• partial and temporary collapse of mentalization
  (Allen 2001).

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• Neglected children have difficulties to
  discriminate between angry, sad and fearful
  expression
• Physically abused children have difficulties
  recognizing sadness and disgust but not anger.
• Both have trend to perform better than control
  children in detecting masked expressions of
  emotions and a bias (increased accuracy) toward
  detection of threat related information such as
  anger.
• Recognizing emotion in faces Developmental
  Effects of child abuse and neglect. Pollak, et
  al.2000.

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Treatments ?
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Basics !!!!

• Genetic
• Prenatal
• Early life
• Childhood
• Teenager
• Adulthood

• Prevention/education/social support
• Prevention/education/social support
• Prevention/education/social support
• Prevention/education/social support
• Prevention/education/social support
• Prevention/education/social support

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Importance of early intervention.

• Effectiveness of home visiting (6.5 during
  pregnancy) by nurses.
• Outcome at 6 months of age, nurses-visited
  infants born to women with low psychological
  resources, in contrast to their control group
  had
• less emotional vulnerability
• higher emotional vitality
• At 21 month they were less language delays.

Home Visiting by Paraprofessionals and by Nurses
a Randomized, controlled Trial. Olds et al
Pediatrics 2002.
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From Brain

• When neurons fire together , they wire
  together (Donald Hebb).
• Experiences turn on the genetic machinery and
  through the synthesis of new proteins, change
  and/or create internal connections in the brain.

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to Mind

• In therapy new learning is verbal (symbolic) and
  non verbal (emotional).
• While treating patients with a very poor quality
  of attachment history (difficulties at emotional
  and mentalization level), it is crucial to pay
  great attention to the attachment quality of
  the therapeutic relationship (collaboration
  repair coherent narratives emotional
  communication)

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• Traditional psychotherapy have focused on changes
  related to the interplay between emotions and
  thoughts.
• Most therapies have essentially ignored changes
  related to bodily states.
• Neurobiology indicate how a global approach
  (including physical well being) of the person is
  essential for improving general condition.

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BPD from Brain to Mind

• Stable attachment lower level of stress
• Education skills training
• Integration of body well being
• Diversification of emotion expression, learning
  cues
• Reactivation of old patterns and re-creation of
  autobiographic narrative that make sense and
  authorize integration
• Increase self awareness and symbolization capacity

• Emotion dysregulation
• Dissociation
• Identity diffusion
• Emotion expression
• Cognitive dysfunctions
• Mentalization deficit
• Learning problems
• Memory problems
• HPA hypereactivity
• Slow return to baseline
• Comorbid depression, substance abuse dependence

• Genetic vulnerability
• Neurobiological vulnerability
• Chaos
• Neglect
• Abuse
• Chronic stress

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• PROVIDE STRUCTURE.
• RELIABLE AND CONSISTENT
• Doing what you have agreed to do
• Avoid expression of extreme emotions
• Inquisitive and curious rather than aloof and
  single minded
• Simple rather than clever.
• ABLE TO DECREASE AROUSAL (calm under fire, be
  matter of fact).
• HELP PATIENTS TO VALIDATE THEIR OWN EXPERIENCES.
• ACCEPT THAT YOU MAKE MISTAKE AND RECOGNIZE
  ENACTMENT.

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Emotion ceases to be suffering as soon as we
form a clear and precise picture of it. Spinoza.
A fragile ego left alone remains fragile.
Medication or superficial support alone is not a
substitute for the feeling that one is understood
by another human being.
Picture by Gregory Colbert
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www.bgrosjean.com
Thank you!
Picture by Gregory Colbert