Thursday, May 7, 2009

The Borderline Personality Disorder Matzoh Ball

My final (for right now) Borderline Personality Disorder Awareness Month installment:

Until just a very short time ago, psychiatry treated borderline personality disorder as one big matzoh ball on the table. Freud and his followers, of course, were to blame for the embarrassment. If only these idiots were to go away, the thinking went, they might take their matzoh ball with them.

Then, psychiatry conceded that yes, the matzoh ball was here to stay, but where to put it? In the schizophrenia casserole? In the bipolar stew?

The borderline matzoh ball didn't deserve it's own dish. A soup, maybe, but certainly not a soup of the day, and definitely not where customers could find it on the menu.

Real mental illness involved scientists talking about tangible stuff such as heritable traits and brain biology, not Freudian cultists babbling nonsense about emotional attachments and integrating aspects of one's self.

Get over it, psychiatry. The borderline matzoh ball is not only here to stay, it rates a featured place on the specials board. In 2008, the NIMH reported on a series of brain imaging studies led by Michael Minzenberg MD of the University of California, Davis.

Previous brain scan research pointed the way by linking a wide range of behaviors to heightened activity in the primitive limbic regions of the brain, most notably the amygdala which mediates arousal and fear. Thus, a hypersensitive limbic system, in response to stress or even just perceived stress, may override the thinking cortical areas of the brain.

In short, people go crazy. Depression, anxiety, mania, aggression, and psychosis are just some of the possible responses. Individuals vulnerable to stress also tend to behave destructively, such as reaching for the bottle or over-eating or sexual promiscuity or self-harm.

There is an added complication: While the limbic region of the brain appears to be overdeveloped, certain cortical regions - most prominently the anterior cingulate cortex (ACC) - appear to be underdeveloped. The ACC, it turns out, is wired into the limbic fear hub.

Perhaps you see where this is going: The ACC acts as a key modulator to limbic over-excitement, and when this part of the brain is not booting up right, the thinking parts of the brain are not only taken off-line, they remain out of commission long enough for people to notice.

In the first study, Minzenberg and colleagues compared the brain scans of borderline patients with healthy controls. While in an MRI machine, the subjects viewed images of "scary faces" (a very common experiment in functional or fMRI). Predictably, the borderline patients displayed overactivity in the amygdala and underactivity in the ACC. In the words of the NIMH:

"Since ACC activity would normally increase to dampen an overactive amygdala, this suggested weak regulation of emotion in the circuit."

Next, the researchers employed structural or anatomical MRI to compare grey matter in the same subjects. The studies found that relative to the controls, the borderline subjects showed increased grey matter density in parts of the amygdala (image below top, red areas) and decreased grey matter in parts of the ACC (image below bottom, yellow area at right). As the NIMH describes it:

"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."

Some quick disclaimers here. The amygdala and the ACC and its connecting circuitry have been implicated with regard to depression and other behaviors. Thus, these studies cannot be cited as irrefutable proof of the borderline diagnosis. For that to happen, we would have to find out what is wrong in the brain that is unique to borderline (or for that matter any other mental illness) and then connect the dots.

What the brain scans do show is that borderline undeniably shares a similar pattern of underlying brain dysregulation as other illnesses regarded as biological, on the same order of magnitude as bipolar and schizophrenia and the rest.

We can even take it a step further. Think of borderline as a condition where its victims constantly view the world as threatening and unpredictable. So, when we're discussing fear factor miscues in the brain, which illness does it best apply to? So ...

Get ready, which illness then becomes the featured dish of biological psychiatry?

Holy cow! The humble Freudian matzoh ball.

Further reading from mcmanweb:

Psychiatry's Big Bang

In addition, an NIMH study under review shows the ventromedial prefrontal cortex modulating amygdala activity through the cingulate. Ah, a part of the brain associated with "thinking," your protection against lashing out like a caged beast. Thus, if you happen to be in the middle of a heated marital dispute, this is probably the time to draw in a slow breath and very calmly say, "I hear you. I think we can work something out."

If your amygdala is doing the talking, however, it may come out something like this: "And besides, you’re lousy in bed!"

At this stage, storming out the door in a huff may be your best option. The amygdala is getting through to the cortex, but the cortex is clearly having difficulty getting through to the amygdala. You probably will be sleeping on the couch tonight, but thankfully you can count on your cortex not to let your behavior escalate from regrettable to extreme. But suppose your top-down circuitry is faulty?

As Dr Meyer-Lindenberg explained, we need a breakdown in the brain’s control mechanisms to become violent. ...


Gina Pera said...

Amusing analogy, John.

I remembering sitting in APA lectures last year on Borderline Personality Disorder, and Powerpoint slide after slide mentioned many of the diagnostic criteria associated with ADHD but ADHD was never mentioned. An amazing oversight given that emotional dysregulation is common among people with untreated/unrecognized ADHD. And, a classic way to describe some of ADHD's challenges is a limbic system unmediated by a strong prefrontal cortex.

Some experts opine that BPD is associated with unrecognized ADHD in childhood that is further complicated by trauma, as is likely to happen when behavior is misinterpreted as willful, bad, etc.

Gina Pera said...


Thus, if you happen to be in the middle of a heated marital dispute, this is probably the time to draw in a slow breath and very calmly say, "I hear you. I think we can work something out."

If your amygdala is doing the talking, however, it may come out something like this: "And besides, you’re lousy in bed!"

John McManamy said...

Hey, Gina. Definitely a lot more work needs to be done on dysregulation in the limbic-cortical circuitry. I can't think of a single mental illness or other type of weird behavior that is somehow not an expression of the front end of the brain and the back end of the brain failing to talk to each other.

Here's something to bounce off of you: If someone with ADD is too scattered in their thinking, then the executive control is lacking to modulate a limbic reaction. Thus, an attentional problem may get mistaken for an emotional or behavioral problem. I think that's your point if I'm correctly interpreting.

Another angle to this: My impression is that sometimes people with ADD may over-focus, almost like OCD. Thus if the thinking part of the brain is obsessed on a particular bad thought (such as visualizing killing your boss), this will be stoking the limbic system.

Thus, again, an attentional dysregulation may be difficult to separate out from an emotional dysregulation. I know Joe Biederman was working on this with kids. As you know, ADD kids are very hard to separate out from BP kids, who are in turn hard to separate out from kids with various conduct disorders.

The kid behaves badly - is it limbic or cortical? At an APA conference, Dr Biederman said with ADD it's cortical and with BP it's limbic. He had brain scans to suggest this was the case.

But a lot more work needs to be done. For the time being I'm working off the premise that with mental illness our brains have a tendency to overload - too much thought, emotion, sensory perception - combined with lack of executive control to handle the overload.

With most mental illness, meds and therapy need to work from both ends of the equation - regulate the overload and enhance executive function. Unfortunately, psychiatry is too dumb to get the balance right. We have mood stabilizers and antipsychotics and anti-anxiety meds to regulate the overload, but at the expense of executive function.

Psychiatry still views treatment success for schizophrenia as knocking out the psychosis, even is it means making their cognitive symptoms and flat affect symptoms worse. And for bipolar psychiatry is equally stupid in medicating the mania out of us.

Meanwhile the meds for executive function (such as the dopamine-enhancers for ADD) risk revving up the overload factor.

Ah, I can see another blog coming...

solution to Borderline said...

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