Breaking News: BPD in Miami

This article was just brought to my attention. It seems Borderline is about to be a bit more high profile. 

Miami Dolphins star has borderline personality disorder

By Amanda Gardner, Health.com

Miami Dolphins wide receiver Brandon Marshall is known as much for his headline-grabbing troubles off the field as he is for his standout play on it.
If he has his way, he’s about to be famous for something else entirely.
In a news conference on Sunday, Marshall told reporters that he suffers from borderline personality disorder, or BPD, a mental illness marked by intense anger, impulsivity, and turbulent interpersonal relationships.
The 27-year-old wide receiver — who received his diagnosis this spring, after seeking treatment at McLean Hospital, in Belmont, Massachusetts — told reporters he wants to be the “face” of BPD.
“My purpose moving forward is to raise awareness of this disorder — how it not only affects the patient but the families and the people in the community,” he said.
Marshall certainly has his work cut out for him. Although an estimated 2% of U.S. adults are affected by the disorder, it remains poorly understood, even among mental health professionals. That’s partly because the symptoms of BPD can look a lot like those of other mental illnesses, such as bipolar disorder, depression, and schizophrenia.
(The term “borderline,” in fact, arose because psychiatrists originally conceived of BPD as occupying the border between psychosis and neurosis, two broad categories of mental illness that aren’t as widely used today.)
BPD can be especially difficult to identify and diagnose because some of the disorder’s hallmarks — including mood swings and intense fears of abandonment — are, in less severe forms, considered to be “normal” human emotions and behavior, says Chris Cargile, M.D., a psychiatrist at the Texas A&M Health Science Center College of Medicine, in Bryan.
“Most of the things we talk about in personality disorders we see in everybody,” says Cargile, who has not treated Marshall and cannot comment on the specifics of his case. “The reason we have the word ‘disorder’ is when those things become problematic. It’s when the intensity level rises to the point where you can’t hold a relationship together for more than a few hours or days, because you can’t trust anybody.”
BPD often manifests in “severe eruptions of depression,” distrust of other people that verges on paranoia, and “frantic” efforts to avoid abandonment, Cargile says.
Suicidal threats and attempts are common; the completed suicide rate in people with BPD is as high as 10%, according to a review of the disorder, published in May in the New England Journal of Medicine, that coincidentally was written by John Gunderson, M.D., a psychiatrist at McLean Hospital who has spoken with Marshall about his condition.
Underlying much of this volatile behavior are an unstable self-image and a pattern of “black-and-white” thinking, Gunderson writes, which can lead to sudden, dramatic switches between feelings of “idealization” and “devaluation” regarding others.
As Patricia Junquera, M.D., an assistant clinical professor of psychiatry at the University of Miami Miller School of Medicine, puts it, “It’s either all or nothing. There are no grays: ‘If you’re not going to be with me, you’re not going to be with anybody.’ They have a lot of security issues that other people might have, but deal with them differently.”
During his press conference, Marshall alluded to the fact that his illness may have played a role in some of his high-profile off-the-field problems, including, most notably, a domestic dispute in April in which Marshall’s wife, Michi Nogami-Marshall, was arrested and charged with stabbing Marshall with a kitchen knife.
(On Sunday, Marshall defended his wife and denied press reports about the incident without providing specifics.)
BPD usually has its roots in early childhood abuse, abandonment, and neglect, and it manifests in poor coping techniques. People with BPD “just don’t know how to deal with their feelings,” says Junquera, who has not treated Marshall.
Men and women with BPD often deal with strong emotions in different ways, she adds. Men represent about one-quarter of all people with BPD, and their inability to manage their feelings sometimes manifests as violence and drug and alcohol abuse.
Women, on the other hand, tend to turn their feelings on themselves, cutting themselves repeatedly or threatening to kill themselves if they believe someone’s going to leave them, she says.
BPD can be very difficult to treat. The remission rate is extremely high, and only about 25% of people with the diagnosis manage to remain employed full-time, according to Gunderson’s review.
Unlike schizophrenia, bipolar disorder, and depression, BPD (and many other personality disorders) tend not to respond to medications, although doctors do sometimes prescribe antidepressants, atypical antipsychotic drugs, and mood stabilizers to BPD patients. Instead, experts tend to rely on talk therapy that stresses how to cope with the feelings of abandonment and other symptoms of the disorder.
“You can treat some symptoms with medications, but the way to truly improve…functioning is with psychotherapy,” Cargile says.
Marshall said he underwent both individual and group therapy at McLean, and seems optimistic about his own prognosis.
“I am not saying that I am cured,” Marshall told reporters during the news conference. “What I am saying today is that I am confident today that with the skills that I have learned and the intensity of the program that I went through that I am in a position where I can live an effective and healthy life.”
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Evidence of Abnormal Amygdala Functioning in BPD

I found an interesting little study paper titled: Evidence of Abnormal Amygdala Functioning in
Background: Intense and rapidly changing mood states are a major feature of BPD; however, there have only been a few studies investigating affective processing in BPD, and in particular no neurofunctional correlates for abnormal emotional processing have been identified so far.
Methods: Six female BPD patients without additional major psychiatric disorder and six age-matched female control subjects underwent functional magnetic resonance imaging (FMRI) to measure regional cerebral hemodynamic changes following brain activity when viewing 12 standardized emotionally aversive slides compared to 12 neutral slides, which were presented in random order.
Results: Our main finding was that BPD subjects but not control subjects were characterized by an elevated blood oxygenation level dependent fMRI signal in the amygdala on both sides. In addition, activation of the medial and inferolateral prefrontal cortex was seen in BPD patients. Both groups showed activation in the temporo-occipital cortex including the fusiform gyrus in BPD subjects but not in control subjects.
Conclusions: Enhanced amygdala activation in BPD is suggested to reflect the intense and slowly subsiding emotions commonly observed in response to even low-level stressors. Borderline subjects’ perceptual cortex may be modulated through the amygdala leading to increased attention to emotionally relevant environmental stimuli.
Borderline personality disorder is thought to arise from affective vulnerability. The inability to regulate one’s affective responses leads to marked, rapidly changing mood states and predisposes patients to various kinds of self-destructive behavior. However, there have been very few medical studies that support this. In this study BPD subjects were checked to ensure that they were neither suffering from additional Axis-I disorders or signs of current alcohol/drug abuse. This was important because the conclusion that this is a BPD trait can be reached, and not a co-morbid symptom attributed to something else. Before each study all the BPD and control patients were assessed to be in a similar baseline emotional state, loaded into an fMRI machine, and shown both neutral and stimulating slides. Brian scans were taken after each slide. The signal intensity was show to be significantly higher in the patients with BPD and not activated at all in the control group. When shown the negative stimuli, the BPD patients showed intense activation patterns in the amygdala. This was not found at all in the control group. The group went on to compare their study findings with other research and found that enhanced amygdala activation is similar to other psychiatric disorders like those noted with Post Traumatic Stress Disorder and Obsessive Compulsive Disorder. From this and other studies it’s suggested that not only is the amygdala active directly by sensory information but also by thoughts and memories. Activation of the amygdala may be regarded as a manifestation of a neurobiological fear reaction. As a conclusion the activation of the amygdala could be a biological indicator of intense unpleasant emotions, especially in relation to certain {perceived negative} stimuli.
It concludes with saying that these findings are consistent with the suggestion that the amygdala serves as a rapid, transient information processing pathway for stimuli that affects behavior. For people with BPD this adaptation may be disturbed which causes emotional reactions to take longer to return to an emotional baseline.
This fear reaction, I find interesting. For those of us with BPD we quite obviously have a fear of abandonment {amongst other things}. But what causes this particular fear itself? To me the answer to this would most likely be found in the childhood/adolescent environment. So is it the environment that alters the development of the brain function, or the brain function that makes one more receptive to certain environmental factors?

Emotion-Regulating Circuit Weakened in Borderline Personality Disorder

I found this article from the National Institute of Mental Health and thought it was interesting. It’s an older article from 2008. As I read more current articles maybe I will eventually compare/contrast them all to see how research has changed over the past few years, or show how it continues to support developing theories.

Emotion-Regulating Circuit Weakened in Borderline Personality Disorder

Grey Matter Changes Linked to Runaway Fear Hub

  
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, 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.
Patients with borderline personality disorder had significantly lower density of grey matter, the brain’s working tissue, in the anterior cigulate cortex, an area (yellow, at right) that regulates the brain’s fear hub (below). MRI scan data shows the difference between patients and controls.
Patients with borderline personality disorder had significantly higher density of grey matter, the brain’s working tissue, in the brain’s fear hub, the amygdala (red areas). MRI scan data shows where patients and controls differed.
An area (anterior  cigulate cortex; orage at the right) that regulates the brain’s fear hub underactivated in patients with borderline personality when they viewed faces with fearful expressions. fMRI scan data reflects differences in activation between patients and controls.
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It’s almost comforting to know that there may be defective regulators in our brains. At the very least it indicates an actual problem and not just something we could potentially be seen as making up. 

Borderline Personality Disorder, Impulsivity, and the Orbitofrontal Cortex

Yeah it’s a mouthful, I know. Since I’ve been talking about impulsive behavior I thought I’d take a look into one potential neurological explanation for impulsivity in Borderline Personality Disorder. Specifically this article focuses on the Orbitofrontal Cortex as a main cause for impulsive behavior.
It was a really well designed study that compared people with BPD to those with legions on the orbitofrontal cortex (damaged OFC), legions in other regions of the brain, and to healthy individuals. They subjected each group to various questionnaires and tests and produced an array of fascinating data which I will attempt to share concisely. So let’s begin shall we.

The goal of this study was to determine if certain aspects of BPD, in particular impulsive behavior, are associated with orbitofrontal cortex dysfunction since this has been associated with disinhibited or socially inappropriate behavior and emotional irregularities; all common features of BPD.
There were many similarities but also some significant differences. However these differences came in areas that were looking to draw conclusions in other areas of the Big 5 personality traits: openness, conscientiousness, extraversion, agreeableness, and neuroticism. This leads to the conclusion that many behaviors may be due to other brain regions, however, since impulsive activity was so similar in both groups it supports the fact that impulsive behavior may be linked to the orbitofrontal cortex.

What are some of the findings?
Similarities:
        –   Personality: Significantly more impulsive.
          – Behavioral Impulsivity: More behaviorally impulsive.  
          – Time Production:  Produced significantly less time than the other two groups
          – Impaired openness to new experience
          – Subjective anger was higher and subjective happiness was lower
Differences:
         –  BPD patients were significantly less extraverted and conscientious, and more neurotic than the other groups.
          – BPD patients had increased levels of sadness, anger, and fear    (<~~~~~ Totally darksiders I don’t care what anyone says).
         –  OFC groups reported a greater overestimation of time passing – indicating a faster subjective sense of time.
          – OFC patients were more insensitive to reward
So what does this all mean? There was significant evidence that both groups were more impulsive as assessed with both behavioral and self-report measures. Since patients with OFC lesions and patients with BPD both performed similarly on tests that indicated more impulsivity and reported more inappropriate behaviors, more BPD traits, more anger, and less happiness than subjects in both of the comparison groups,it can be assumed that there is a connection in these areas. The tests also indicated they were less open to experience and have faster perceptions of time. These findings suggest that the orbitofrontal cortex functions may be related to these aspects of BPD but not to other BPD traits (such as levels of extraversion, conscientiousness, neuroticisms, and emotion).   Therefore it concludes that impulsive behavior could be related to orbitofrontal cortex function.
One thing I found interesting was the time studies. Patients with BPD and OFC lesions both had significantly lower time latencies on behavioral impulsivity tasks.  This result may be related to a desire to complete a task fast, combined with a lack of sensitivity to punishment (OFC lesions) and perhaps with the desire for the reward of finishing sooner (BPD). So, since those with BPD are more emotionally receptive to reward we are likely to rush into something in anticipation of gaining the end benefit. Both groups also produced less time than the other groups. A common cause could be a higher level of frustration in waiting for time to elapse. This study supports evidence that impulsivity and time perception are related. “The frustration in waiting and/or the faster cognitive tempo that may cause patients with orbitofrontal cortex lesions and patients with BPD to under produce time may also be related to some of the inappropriate social and emotional behaviors they display.”
However this study also found that patients with BPD were more neurotic, less extraverted and less conscientious than all other groups. Since the OFC legion group was similar to the other groups this shows that these areas are not related to the orbitofrontal cortex region. Other areas that are probably unrelated to the orbitofrontal cortex region are: higher levels of emotionality. One of the studies showed that an increased sensitivity to punishment might make patients with BPD more emotional, and the higher level of emotionality might then contribute to impulsive behavior.
This study was very well rounded in it does support exactly what it set out to prove, by both demonstrating direct correlations to impulsive behavior and by ruling out behavior that is not associated with that area of the brain. It goes on to say, “Our findings relate well to the hypothesis that the amygdale and orbitofrontal cortex act as part of an integrated neural system, as well as alone, in guiding decision making and adaptive response{s}. Patients with BPD have some deficits that can be related to the functions performed by the orbitofrontal cortex. These deficits might be related to smaller volume of the orbitofrontal cortext or to lower levels of activity in the orbitofrontal cortex.”
Fascinating. I’ve been meaning to take a look at more neurological and biogenetic causes for Borderline Personality Disorder for quite a while now. I think this is an interesting start, if not a bit dry. I hope it was informative at least. 

"Are you one of us?"

A Reader brought this article to my attention and I wanted to share it. It was on the front of the NY Times this past week. Marsha M. Linehan, as I’ve discussed before, is the pioneer of Dialectical Behavior Therapy which is one of the most prominent courses of treatment for Borderline Personality Disorder. I’m going to go through and underline some things I find particularly poignant. Maybe I’ll talk about them tomorrow. Regardless, I think it’s an insightful read.

Expert on Mental Illness Reveals Her Own Fight
By BENEDICT CAREY
Published: June 23, 2011

HARTFORD — Are you one of us?
The patient wanted to know, and her therapist — Marsha M. Linehan of the University of Washington, creator of a treatment used worldwide for severely suicidal people — had a ready answer. It was the one she always used to cut the question short, whether a patient asked it hopefully, accusingly or knowingly, having glimpsed the macramé of faded burns, cuts and welts on Dr. Linehan’s arms:
“You mean, have I suffered?”
“No, Marsha,” the patient replied, in an encounter last spring. “I mean one of us. Like us. Because if you were, it would give all of us so much hope.”
“That did it,” said Dr. Linehan, 68, who told her story in public for the first time last week before an audience of friends, family and doctors at the Institute of Living, the Hartford clinic where she was first treated for extreme social withdrawal at age 17. “So many people have begged me to come forward, and I just thought — well, I have to do this. I owe it to them. I cannot die a coward.”
No one knows how many people with severe mental illness live what appear to be normal, successful lives, because such people are not in the habit of announcing themselves. They are too busy juggling responsibilities, paying the bills, studying, raising families — all while weathering gusts of dark emotions or delusions that would quickly overwhelm almost anyone else.
Now, an increasing number of them are risking exposure of their secret, saying that the time is right. The nation’s mental health system is a shambles, they say, criminalizing many patients and warehousing some of the most severe in nursing and group homes where they receive care from workers with minimal qualifications.
Moreover, the enduring stigma of mental illness teaches people with such a diagnosis to think of themselves as victims, snuffing out the one thing that can motivate them to find treatment: hope.
“There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life,” said Elyn R. Saks, a professor at the University of Southern California School of Law who chronicles her own struggles with schizophrenia in “The Center Cannot Hold: My Journey Through Madness.” “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”
These include medication (usually), therapy (often), a measure of good luck (always) — and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places, these former patients say: love, forgiveness, faith in God, a lifelong friendship.
But Dr. Linehan’s case shows there is no recipe. She was driven by a mission to rescue people who are chronically suicidal, often as a result of borderline personality disorder, an enigmatic condition characterized in part by self-destructive urges.
“I honestly didn’t realize at the time that I was dealing with myself,” she said. “But I suppose it’s true that I developed a therapy that provides the things I needed for so many years and never got.”
‘I Was in Hell’
She learned the central tragedy of severe mental illness the hard way, banging her head against the wall of a locked room.
Marsha Linehan arrived at the Institute of Living on March 9, 1961, at age 17, and quickly became the sole occupant of the seclusion room on the unit known as Thompson Two, for the most severely ill patients. The staff saw no alternative: The girl attacked herself habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on.
The seclusion room, a small cell with a bed, a chair and a tiny, barred window, had no such weapon. Yet her urge to die only deepened. So she did the only thing that made any sense to her at the time: banged her head against the wall and, later, the floor. Hard.
“My whole experience of these episodes was that someone else was doing it; it was like ‘I know this is coming, I’m out of control, somebody help me; where are you, God?’ ” she said. “I felt totally empty, like the Tin Man; I had no way to communicate what was going on, no way to understand it.”
Her childhood, in Tulsa, Okla., provided few clues. An excellent student from early on, a natural on the piano, she was the third of six children of an oilman and his wife, an outgoing woman who juggled child care with the Junior League and Tulsa social events.
People who knew the Linehans at that time remember that their precocious third child was often in trouble at home, and Dr. Linehan recalls feeling deeply inadequate compared with her attractive and accomplished siblings. But whatever currents of distress ran under the surface, no one took much notice until she was bedridden with headaches in her senior year of high school.
Her younger sister, Aline Haynes, said: “This was Tulsa in the 1960s, and I don’t think my parents had any idea what to do with Marsha. No one really knew what mental illness was.”
Soon, a local psychiatrist recommended a stay at the Institute of Living, to get to the bottom of the problem. There, doctors gave her a diagnosis of schizophrenia; dosed her with Thorazine, Librium and other powerful drugs, as well as hours of Freudian analysis; and strapped her down for electroshock treatments, 14 shocks the first time through and 16 the second, according to her medical records. Nothing changed, and soon enough the patient was back in seclusion on the locked ward.
“Everyone was terrified of ending up in there,” said Sebern Fisher, a fellow patient who became a close friend. But whatever her surroundings, Ms. Fisher added, “Marsha was capable of caring a great deal about another person; her passion was as deep as her loneliness.”
“Everyone was terrified of ending up in there,” said Sebern Fisher, a fellow patient who became a close friend. But whatever her surroundings, Ms. Fisher added, “Marsha was capable of caring a great deal about another person; her passion was as deep as her loneliness.”
A discharge summary, dated May 31, 1963, noted that “during 26 months of hospitalization, Miss Linehan was, for a considerable part of this time, one of the most disturbed patients in the hospital.”
A verse the troubled girl wrote at the time reads:
They put me in a four-walled room
But left me really out
My soul was tossed somewhere askew
My limbs were tossed here about
Bang her head where she would, the tragedy remained: no one knew what was happening to her, and as a result medical care only made it worse. Any real treatment would have to be based not on some theory, she later concluded, but on facts: which precise emotion led to which thought led to the latest gruesome act. It would have to break that chain — and teach a new behavior.
“I was in hell,” she said. “And I made a vow: when I get out, I’m going to come back and get others out of here.”
Radical Acceptance
She sensed the power of another principle while praying in a small chapel in Chicago.
It was 1967, several years after she left the institute as a desperate 20-year-old whom doctors gave little chance of surviving outside the hospital. Survive she did, barely: there was at least one suicide attempt in Tulsa, when she first arrived home; and another episode after she moved to a Y.M.C.A. in Chicago to start over.
She was hospitalized again and emerged confused, lonely and more committed than ever to her Catholic faith. She moved into another Y, found a job as a clerk in an insurance company, started taking night classes at Loyola University — and prayed, often, at a chapel in the Cenacle Retreat Center.
“One night I was kneeling in there, looking up at the cross, and the whole place became gold — and suddenly I felt something coming toward me,” she said. “It was this shimmering experience, and I just ran back to my room and said, ‘I love myself.’ It was the first time I remember talking to myself in the first person. I felt transformed.”
The high lasted about a year, before the feelings of devastation returned in the wake of a romance that ended. But something was different. She could now weather her emotional storms without cutting or harming herself.
What had changed?
It took years of study in psychology — she earned a Ph.D. at Loyola in 1971 — before she found an answer. On the surface, it seemed obvious: She had accepted herself as she was. She had tried to kill herself so many times because the gulf between the person she wanted to be and the person she was left her desperate, hopeless, deeply homesick for a life she would never know. That gulf was real, and unbridgeable.
That basic idea — radical acceptance, she now calls it — became increasingly important as she began working with patients, first at a suicide clinic in Buffalo and later as a researcher. Yes, real change was possible. The emerging discipline of behaviorism taught that people could learn new behaviors — and that acting differently can in time alter underlying emotions from the top down.
But deeply suicidal people have tried to change a million times and failed. The only way to get through to them was to acknowledge that their behavior made sense: Thoughts of death were sweet release given what they were suffering.
“She was very creative with people. I saw that right away,” said Gerald C. Davison, who in 1972 admitted Dr. Linehan into a postdoctoral program in behavioral therapy at Stony Brook University. (He is now a psychologist at the University of Southern California.) “She could get people off center, challenge them with things they didn’t want to hear without making them feel put down.”
No therapist could promise a quick transformation or even sudden “insight,” much less a shimmering religious vision. But now Dr. Linehan was closing in on two seemingly opposed principles that could form the basis of a treatment: acceptance of life as it is, not as it is supposed to be; and the need to change, despite that reality and because of it. The only way to know for sure whether she had something more than a theory was to test it scientifically in the real world — and there was never any doubt where to start.
Getting Through the Day
“I decided to get super-suicidal people, the very worst cases, because I figured these are the most miserable people in the world — they think they’re evil, that they’re bad, bad, bad — and I understood that they weren’t,” she said. “I understood their suffering because I’d been there, in hell, with no idea how to get out.”
In particular she chose to treat people with a diagnosis that she would have given her young self: borderline personality disorder, a poorly understood condition characterized by neediness, outbursts and self-destructive urges, often leading to cutting or burning. In therapy, borderline patients can be terrors — manipulative, hostile, sometimes ominously mute, and notorious for storming out threatening suicide.
Dr. Linehan found that the tension of acceptance could at least keep people in the room: patients accept who they are, that they feel the mental squalls of rage, emptiness and anxiety far more intensely than most people do. In turn, the therapist accepts that given all this, cutting, burning and suicide attempts make some sense.
Finally, the therapist elicits a commitment from the patient to change his or her behavior, a verbal pledge in exchange for a chance to live: “Therapy does not work for people who are dead” is one way she puts it.
Yet even as she climbed the academic ladder, moving from the Catholic University of America to the University of Washington in 1977, she understood from her own experience that acceptance and change were hardly enough. During those first years in Seattle she sometimes felt suicidal while driving to work; even today, she can feel rushes of panic, most recently while driving through tunnels. She relied on therapists herself, off and on over the years, for support and guidance (she does not remember taking medication after leaving the institute).
Dr. Linehan’s own emerging approach to treatment — now called dialectical behavior therapy, or D.B.T. — would also have to include day-to-day skills. A commitment means very little, after all, if people do not have the tools to carry it out. She borrowed some of these from other behavioral therapies and added elements, like opposite action, in which patients act opposite to the way they feel when an emotion is inappropriate; and mindfulness meditation, a Zen technique in which people focus on their breath and observe their emotions come and go without acting on them. (Mindfulness is now a staple of many kinds of psychotherapy.)
In studies in the 1980s and ’90s, researchers at the University of Washington and elsewhere tracked the progress of hundreds of borderline patients at high risk of suicide who attended weekly dialectical therapy sessions. Compared with similar patients who got other experts’ treatments, those who learned Dr. Linehan’s approach made far fewer suicide attempts, landed in the hospital less often and were much more likely to stay in treatment. D.B.T. is now widely used for a variety of stubborn clients, including juvenile offenders, people with eating disorders and those with drug addictions.
“I think the reason D.B.T. has made such a splash is that it addresses something that couldn’t be treated before; people were just at a loss when it came to borderline,” said Lisa Onken, chief of the behavioral and integrative treatment branch of the National Institutes of Health. “But I think the reason it has resonated so much with community therapists has a lot to do with Marsha Linehan’s charisma, her ability to connect with clinical people as well as a scientific audience.”
Most remarkably, perhaps, Dr. Linehan has reached a place where she can stand up and tell her story, come what will. “I’m a very happy person now,” she said in an interview at her house near campus, where she lives with her adopted daughter, Geraldine, and Geraldine’s husband, Nate. “I still have ups and downs, of course, but I think no more than anyone else.”

After her coming-out speech last week, she visited the seclusion room, which has since been converted to a small office. “Well, look at that, they changed the windows,” she said, holding her palms up. “There’s so much more light.”

Oxytocin and Borderline Personality Disorder

I saw this very recent article on the effects of Oxytocin and Borderline Personality Disorder and thought I would share. My immediate thought was, they are doing some wild things to study BPD, however this still means, they’re doing things to study BPD.

Oxytocin and Borderline Personality Disorder

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Often referred to as the “love drug” or “love hormone”, oxytocin has attracted increasing interest from researchers in recent years. It was originally shown to modulate aspects of social attachment and pair bonding in animals such as the female prairie vole, whose monogamous nature is dependent on oxytocin. Recent research in humans has shown that oxytocin increases trust behavior in economic exchanges and increases perception of trustworthiness in human faces, as well as promoting emotion recognition and altruism. This evidence inspired hopes among some, particularly in the mainstream media, that science might have found a possible pharmacological target for humans who show deficits in prosocial behavior.
But recent evidence has complicated the narrative a bit.

Research has shown that oxytocin plays a role in increased emotional reactivity to both positive and negative social cues. For example, one study from 2009 (Shamay-Tsoory et al) had participants engage in a game of chance with another player (the actor). In one condition, the actor was made to win more than the participant, evoking feelings of envy in the participant. In another condition, the actor was made to lose more than the participant, evoking feelings of “schaudenfrude” or gloating. Participants who were administered oxytocin before playing showed increases in both envy and schaudenfrude (if oxytocin was involved only in enhancing prosocial behavior, we would expect to see the opposite result.) Other research has shown oxytocin increased approach behavior or affiliative drive rather than regulating positive or negative responding per se. And one recent study showed that oxycotin led humans to self-sacrifice for their own group while showing increased aggression toward out-group members. The gist of this set of findings is that oxytocin doesn’t seem to bias individuals toward the positive, but rather can magnify whatever “stimuli” happens to be in someone’s attentional spotlight, be it bad or good, thereby generating an increase in corresponding positive or negative emotional responses.

Jennifer Bartz and colleagues (2010) were curious to explore whether oxytocin could “correct” deficits in pro-social behavior in individuals with borderline personality disorder (BPD), a population famous for emotional instability, extreme impulsive behavior and identity confusion. People with BPD tend to be involved in intense, emotionally volatile relationships characterized by frequent arguing, repeated breakups and extreme aggression. This behavior often extends beyond their romantic relationships, as BPD individuals have also been shown to have difficulty cooperating with strangers. The existing body of research, Bartz et al suggested, offers up contrary predictions. On the one hand, oxytocin could be helpful in reducing the negative behaviors normally associated with BPD in favor of kinder, gentler behavior towards others. Alternatively, oxytocin might have increasingly negative effects for people with BPD, who are chronically concerned with (lack of) trust and abandonment and have difficulty cooperating with others. They’re essentially fixed in a constitutively negative state when it comes to social interactions and increased oxytocin could decrease prosocial behavior even further. Additionally (or alternatively), the oxytocin system might be dysregulated in BPD and could produce different responses (vs. control) to oxytocin as a result.

Bartz and company designed an experiment in which the participant was paired with a partner (in reality, a virtual “computer” partner) to engage in an economic game. In this game, the participant was to make one of two choices that involved financial rewards. The catch was that the amount of the reward was also dependent upon the choice that their “partner” made.

Both players clearly make the most money if they both choose strategy A. But because the player has to make the choice before the partner, the decision involves an element of trust (if your partner defects, you get nothing. If your partner trusts you and you defect, you get $4 and she gets nothing.)

So, what did they find?

Results showed the following:

1. BPD people trusted their partners in an economic game less after they received oxycotin than when they received a placebo.

2. Additionally, when asked if they would be more likely to make a hypothetical decision that would punish their partner, even when they knew their partner had extended trust toward them, they were more likely to punish after Oxytocin than placebo.

Administration of oxytocin to BPD individuals actually decreased pro-social behavior (and increased antisocial behavior). As the experimenters suggest, increasing the salience of a social cue that makes trust issues salient may have caused BPD participants to rely on their normal strategy for trust-dependent social interactions; that is, defect and punish the partner. Or it might have motivated approach/affiliative behaviors which triggered memory of past experiences gone awry and set off chronic and ever-present concerns about trust and rejection (e.g. “reject and punish them before they can do the same to me.”). Finally, the experimenters suggest the possibility that the oxytocin system itself may be dysregulated.

In short, the evidence doesn’t offer overwhelming support for the notion that exogenously-administered oxytocin will be a useful clinical treatment for people with pro-social deficits, such as those with BPD. Additionally, it’s difficult to imagine long-term benefits of oxytocin given that it’s half life when administered intranasally is only about three minutes. It’s been said that the most of the real action with regards to oxytocin is on the receptor end.

——————–

Something to think about for sure. Drugs have unpredictable side effects to begin with but couple this with the chemistry of someone that is already outside of normal reactivity? I’m almost surprised they thought this would help. It increases mood. People with BPD don’t have normal moods, by definition.
People with borderline aren’t only aggressive and disruptive. Our moods run the gamut of angry to ecstatic, albeit more rapidly and more intensely than normal. So by extension I would expect that not only would it heighten the good moods, but also the rest of our reactive moods.
Oxytocin, like any drug, works differently for different people, and in the best of cases elevates a good mood. To me this makes me wonder if ideas of trust, paranoia are linked to the same emotional receptors. It seems that the study did indicate that moods were elevated but these other aspects were impacted differently than in a neuro-typical brain. Perhaps this points to a different area of the affected borderline brain to be taken into consideration for synapses connections.
Moral of the story: Drugs are bad kids…. And apparently don’t mix well with personality disorders.  

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ElectroShocking

Shocking news about Electroshock therapy. Then again, maybe it’s not so shocking afterall… Regardless, I’m rather fascinated so I thought I would share. Enjoy!

Hyperactive Nerve Cells May Contribute to Depression
Identification of cellular mechanism could lead to novel and effective treatments
Scientists at BNL, Cold Spring Harbor Laboratory, and the University of California, San Diego (USCD) School of Mediciine, have identified hyperactive cells in a tiny brain structure that may play an important role in depression. The study, conducted in rats and appearing in the February 24, 2011 issue of Nature, is helping to reveal a cellular mechanism for depressive disorders that could lead to new, effective treatments.
The research provides evidence that inhibition of this particular brain region – the lateral havenula – using implanted electrodes can reverse certain behaviors associated with depression, and also provides a mechanism to explain this effect. These findings lend support to the use of deep brain stimulation as a clinical treatment for people with long-standing, treatment-resistant depression.
This research was supported through Laboratory Directed Research and Development at BNL, and by the Simons Foundation, the Dana Foundation, the National Institute of Mental Health, and a Shiley-Marcos endowment at UCSD.
“This research identifies a new anatomical circuit in the brain that mediates depression, and shows how it interacts with the brain’s reward system to trigger a  constant disappointment signal – which certainly would be depressing,” said Fritz Henn, a neurobiologist and psychiatrist at BNL and Cold Spring Harbor laboratories and a co-investigator on the research. “But,” he added, “identifying this circuit and how it works may open new doors to reversing these effects.”
For example, said co-investigator Roberto Malinow, a professor of neurosciences at the USCD School of Medicine, “It’s possible that the genes specifically expressed in these neurons could be targeted genetically or pharmacologically in order to manipulate them and reduce depression.”
Scientists have known that cells in the lateral habenula are activated by negative or unpleasant events, including punishment and disappointment, such as when you don’t get an expected reward. It may seem intuitive that such negative stimuli can lead to depression, but not everyone who experiences disappointment collapses into a state of  helplessness. To explore this connection, the scientists took a closer look at the brain circuits.
Overall, the results showed that these lateral habenula nerve cells were hyperactive in the depressed animals but not in the control subjects. Furthermore, the degree of hyperactivity coincided with the degree of helplessness.
To explore whether electrical stimulation could potentially reverse this reward-dampening effect, the researchers placed a stimulating electrode in the lateral habenula and measured the effects on the brain cells leading to the reward center. They found that electrical stimulation of hyperactive habenula brain cells markedly decreased excitatory activity leading ot the reward center.
“The study provides a cellular mechanism that may explain the hyperactive of the lateral habenula nerve cells observed in depressed  humans and animal models of depression, as well as why ‘silenceing’ these circuits, whether surgically or pharmacologically, can reduce depression-like symptoms in animals,” Henn said.

Be Specific, please.

Hazy Recall as a Signal Foretelling Depression
By ALASTAIR GEE
OXFORD, England — The task given to participants in an Oxford University depression study sounds straightforward. After investigators read them a cue word, they have 30 seconds to recount a single specific memory, meaning an event that lasted less than one day.
Cues may be positive (“loved”), negative (“heartless”) or neutral (“green”). For “rejected,” one participant answered, “A few weeks ago, I had a meeting with my boss, and my ideas were rejected.” Another said, “My brothers are always talking about going on holiday without me.”
The second answer was wrong — it is not specific, and it refers to something that took place on several occasions. But in studies under way at Oxford and elsewhere, scientists are looking to such failures to gain new insights into the diagnosis and treatment of depression. They are focusing not on what people remember, but how.
The phenomenon is called overgeneral memory, a tendency to recall past events in a broad, vague manner. “It’s an unsung vulnerability factor for unhelpful reactions when things go wrong in life,” said Mark Williams, the clinical psychologist who has been leading the Oxford studies.
Some forgetting is essential for healthy functioning — “If you’re trying to remember where you parked the car at the supermarket, it would be disastrous if all other times you parked the car at the supermarket came to mind,” said Martin Conway, a cognitive psychologist at the University of Leeds in England. But, a chronic tendency to obliterate details has been linked to longer and more intense episodes of depression.
Now researchers at Oxford, Northwestern University in Illinois and other universities are conducting studies with thousands of teenagers to determine whether those with overgeneral memory are more likely to develop depression later on. If so, then a seemingly innocuous quirk of memory could help foretell whether someone will experience mental illness.
There are already some clues in this direction. In lab experiments Dr. Williams has induced an overgeneral style in subjects by coaching them to recall types of events (“when I drive to work”) rather than specific occasions (“when I drove to work last Saturday”). He found they were suddenly less able to solve problems, suggesting that overgeneral memory is capable of producing one symptom of depression.
And an unusual paper suggests that overgeneral memory is a risk factor for post-traumatic stress disorder. Scientists at the University of New South Wales in Sydney, Australia, assessed 46 firefighters during their initial training and again four years later, when all had experienced traumatic events like seeing comrades injured or killed. Those who could not recall the past in specific detail during the first assessment were much likelier to have developed the disorder by the later one.
“People with P.T.S.D. tend to ruminate at a very categorical, general level about how unsafe life is, or how weak I am, or how guilty I am,” said the lead author, Richard Bryant. “If I do that habitually and then I walk into a trauma, probably I’m going to be resorting to that way of thinking and it’s going to set me up for developing P.T.S.D.”
Dr. Williams stumbled across overgeneral memory by chance in the 1980s. He had asked research subjects to write down the memories elicited by certain cues, and when they left the page blank he thought he had given unclear instructions. Soon he began to wonder about the significance of the omissions.
Usually people seeking a particular memory traverse a mental hierarchy, Dr. Williams said. They begin by focusing on a general description (“playing ball with my brother”) and then narrow the search to a specific event (“last Thanksgiving”). Some people stop searching at the level of generality, however and are probably not conscious of having done so.
This is sometimes a helpful response, which is perhaps why overgeneral memory exists in the first place — it can be a useful way to block particular traumatic or painful memories. Researchers at Leuven discovered that students who did poorly on exams and were more specific took longer to recover from the disappointment than those who were more general. The overgeneral students thought less about the details of what happened and so fared better, at least in the short term. “
“But these researchers say problems can arise when overgenerality becomes an inflexible, blanket style.
Without detailed memories to draw upon, dispelling a black mood can seem impossible. Patients may remember once having felt happy, but cannot recall specific things that contributed to their happiness, like visiting friends or a favorite restaurant.
“If you’re unhappy and you want to be happy, it’s helpful to have memories that you can navigate through to come up with specific solutions,” Dr. Williams said. “It’s like a safety net.”
Some experts think such insights could also be helpful in treating depression. For example, Spanish researchers have reported that aging patients showed fewer symptoms of depression and hopelessness after they practiced techniques for retrieving detailed memories.
“When we have a disorder like depression, which is so common and so disabling for so many people, we need to increase the tools in our tool kit,” said Susan Mineka, a clinical psychologist working on a study by Northwestern University and the University of California, Los Angeles, that is testing for depression and anxiety risk factors, including overgeneral memory. “If we could change their overgeneral memory, maybe that would help even more people stay better for longer.”
Dr. Williams has found that specificity can be increased with training in mindfulness, a form of meditation increasingly popular in combating some types of depression. Subjects are taught to focus on moment-to-moment experiences and to accept their negative thoughts rather than trying to avoid them. It may help by making people more tolerant of negative memories and short-circuit the impulse to escape them, which can lead to overgenerality.
Meditation means that for some, the past is no longer such a heavy burden.
“I always tried to forget the past, the very bad past that made me depressed when my husband died,” said Carol Cattley, 76, who attended a mindfulness course here taught by Dr. Williams. “I’m much more interested in it now.”
I found this interesting, and relatable. I cannot recall a single period of being happy because generally what I remember is being depressed. I can remember instances and events when I’ve been happy, but I have to work much harder to draw on these and they don’t span any length of time. My depressed moods are overarching where my happy moods are temporary injections.The negative experiences and emotions I’ve had seem to permeate the expanses of my mind and coat the good instances in cyanide. No sugar coating here. I do notice that I think back to things and stop at a certain, more general, point instead of continuing to the more specific. For instance, I’ll think about spending time at movie night with Friend. In general I remember being withdrawn from the crowd, irritable, and depressed. I have to push myself to think of specific nights or hours or minutes where this was not how I felt. I have had a lot of great times hanging out, laughing, joking and just being goofy with Friend and my other friends that come along, but these aspects of recollection are not what immediately springs to mind.  I experience happiness, but my recollection of it is muted. I have to put in that little added effort to bring up the happy moments. It makes sense that this kind of memory generalization would lead to or contributes to depression. It’s weird. For as much as I focus on how different my BPD brain is from your average persons’, it still strikes me just how different other people experience the world and just how much those little quirks in our biology can morph our entire perception and interaction in the world.

Thought Control is Mind Control

I found an article written by Dr. Amen who’s a psychiatrist, neuroscientist and brain-imaging specialist. It’s about how to conquer negativity and encourage positive thoughts. It’s not about Borderline Personality Disorder per say. It’s aimed at people that do have negative thoughts but are basically ‘normal’ (meaning: don’t have a personality disorder). However I found what he had to say runs parallel to BPD.
The article is about negative thinking, what he calls ANTs = Automatic Negative Thinking. These are thoughts that automatically pop into your head, but don’t necessarily have any rational hold. Or if they do, they run away with you instead of allowing for the ability to come up with solutions instead of dwelling on them. The thoughts that jump into your head automatically after something triggers them and refuse to go away. For me these thoughts run rampant and spin me down into a dark hole that I can’t climb out of.
He goes on to say that powerful thoughts can lead to physical reactions. Negative thoughts actually release chemicals in your brain that do make you feel bad. The opposite is true too, the happy, the positive can lead to chemical release that makes you feel good.
Therapists have identified 10 ‘species’ of the automatic negative thoughts. (I think the term ANTs just sounds ridiculous. I can’t take it seriously.)
1.)  All or nothing (thinking in black and white).  This is what Splitting is.
2.) Always thinking (overgeneralizing). Well, yeah.
3.)  Focusing on the negative (ignoring the positive). When things are always bad, when nothing turns out how you need it to, when every little thing shakes your foundation, it’s hard to think about the positive. On the other hand, if you swing {hyper}manic, it’s the opposite, everything can be positive, everything is superhuman, everything is achievable. I think the mood swings of someone with BPD can be a little too changeable for this, but generally speaking I think the principle here is true.
4.) Think with your feelings (believeing negative feelings without evidence). Obviously. BPD is all about emotional dysregulation. Emotions that take control, cloud your judgment, and make you act in ways that most people wouldn’t.
5.)  Guilt beating (thinking in words like “should”, “must”, “ought to). I do this a lot. Believe I should be other than I am, should have done something better, was not good enough at something else, failed myself in some way… I tell myself that I’m not good enough if I can’t be perfect.
6.)  Labeling (attaching negative labels to yourself and others). For someone with BPD I think this is an extension of Splitting. I label someone as all good (ex. Roommate). I label someone as all bad (Friends wife). It may be both all good, or all bad for the same person at different times, depending on the last interaction (ex. Friend or myself).
7.)  Fortune Telling (predicting the future in a negative way). Hopelessness, abandonment, believing that eventually everyone will leave, things will always turn out devastatingly wrong. Just walking into a situation and knowing it’s going to turn out bad for you. I find this usually happens worse when it’s something I really want.
8.)  Mind Reading (believing you know what someone else is thinking). This goes hand in hand with hypersensitivity. When you’re so attuned to what someone does, if there’s any variation, anything to shake that tenuous stability, there’s no helping the wild thoughts that run away to figure out why someone has changed in some way. Even if that change is miniscule.
9.)  Blame (Blaming others for you problems). If he just did this, if she felt this way, if I wasn’t so misunderstood… these tend to be the kinds of thoughts I have to give ‘reasons’ for my negative feelings. 
10.)               Denial (refusing to admit you have a problem). Heh, I don’t think this is really my issue, or anyone’s issue that has BPD and is seeking help or treatment. Well, maybe. Identifying ALL the areas that need helping I can see where there can be denial.
The first step is to realize these things are a problem. Keeping in mind that these thoughts happen may help figure out how to change them.
Everybody lies
To combat these he makes a good point: Thoughts can lie; they lie a lot. However you don’t have to believe every thought that pops into your head. But how do you determine which thoughts you can believe? All things in life aren’t positive, some things are negative. Just because you’re paranoid doesn’t mean you’re wrong, sort of thing. The problem is they feel like the truth. These are what automatically popped into my head, and it’s pretty obvious to me that they’re self-defeating in term of incorporating a helpful idea. I often fight against things that are good for me, and I don’t know why.
In order to get ahold of these thoughts and recognize which ones are not rational he makes a suggestion. Write them down. “The simple act of writing down your thoughts helps get them out of your head and begins to diffuse any negative feelings so you start to feel better”.  This is something I do almost daily. I’ve kept journals since I was 12/13 years old. For me it only tends to be a temporary fix. It doesn’t help the irrational thoughts from coming back in the future, or even the next day, but it does help me get ahold of them and allow me to work through them at the time. I can’t always write as soon as I have ridiculous thoughts, so often they  stay with me for days, weeks. When I do have time to write I do feel calmer. I’m able to look at the problem and try to sort things out. If nothing else, it reminds me of the things I need to talk about in therapy. My therapist encourages me to write every day. If I’m comfortable I read what I’ve written in session so that we can work on these things.    I try to write everyday but sometimes I’m just too busy or I don’t want to… and sometimes I want to dwell on my problem. I want to hold things to me, believe that these things are true, not my fault, feel misunderstood so I can believe these kinds of thoughts are justified. I know this isn’t rational but sometimes I hold things to me and don’t want to let them go.  I know this is something I need to work on. I can generally get my thoughts down on paper, and it does help me put things into perspective for a while.

Continue with: write down the ‘negative’ situation that brought about the negative thoughts and feelings, identify the moods felt during the situation, write down the automatic thoughts that were experienced when that certain mood was felt, identify the evidence that supports these thoughts, identify the evidence that does not support these thoughts, next identify the fair and balanced thoughts about the situation, and finally observe the new mood and think about what to do.

The problem with this article, for me, is that when you have a personality disorder you can’t just think your way out of the barrage of overblown thoughts that accost you . Beat you into submission mastered by your emotions.  You feel them whether you want to or not and no amount of telling yourself otherwise alleviates them. If it was as simple as remembering a few principles**, PDs wouldn’t be a problem for anyone that wants to change.  I can’t internalize a lot of these, and unless I read them every single day, my neurotic thoughts will crowd out the helpful ones. Maybe other people can remember them and use these techniques to keep some calm. Find a little relief. A way of infusing some rational explanation into the irrational behavior.  
** This is the point of therapy. However therapy realizes that it takes time, practice, and work to change these behaviors. It’s not as simple as reading an article.