Tuesday, May 20, 2014

Borderline Personality Disorder: Why They Don't “Get Used to It.”

At the annual meeting of the American Psychiatric Association in New York this year, I learned about a new finding from one study with patients who exhibit borderline personality disorder (BPD). The same finding also applied, although to a lesser degree, to those with avoidant personality disorder (AVD), which is pretty much identical to the diagnosis of Social Phobia.  I suspect that the reasons for the similar findings may be different for the two disorders.

The finding involved a part of the brain called the Amygdala. This little doohickey is central to a lot of brain functions, but in particular, it is the center for the body’s “fight or flight” response. I always though it fascinating  that the amygdala also has specific cells which respond only to one’s own mother (or other primary female attachment figure) and nothing and nobody else, and other specific cells which respond only to one’s father (or other primary male attachment figure). 

Although one cannot prove such things, this fact suggests to me that primary attachment figures may be the most potent of all of the environmental triggers to fear-based flight or fight reactions. They are certainly more powerful that a therapist can ever be for doing so, for instance.

The finding may relate to one of the primary symptoms of BPD, which goes by a variety of names. In the actual DSM criteria, it is described as “affective instability, or marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days.)” It is also called high reactivity, and lay people often label it hypersensistivity. In psychological tests, it is called neuroticism. Clearly, amygdala activation is intrinsic to this phenomenon.

Therapists have a tendency to think that patients with BPD over-react because they misperceive the behavior of others as being emotional slights, when the behavior is not at all meant as such. In fact, these therapists do not even know to what exactly the patient may be reacting to, or alternatively, that sometimes patients with BPD feign such reactions in order to provoke a specific response in others in order to recruit them to be enablers of the patients’ spoiler role.

For example, one patient would go ballistic if anyone ever even implied that her mother might have been a loving parent. Of course, if one knew all the horrible things her mother had done to her, one could easily see why she would find such a comment annoying - to say the least!

The study I am discussing here is by Harold Koenigsberg and others (Journal of the American Psychiatric Association 171:82-90, January 2014). Study participants were asked to look at a series of pictures with either highly negative or neutral content, and the activation of the amygdala and another region of the brain called the dorsal anterior cingulate was measured using a specific type of brain scan. The subjects also subjectively rated their emotional responses to the pictures. 

Exposure to these pictures and these measurements were then repeated. Repeated only once, I’m afraid. The study would have been a lot more powerful if they had repeated the exposure several times.

The changes in emotional arousal and brain activation after a repeat viewing of the negative images was small but signficantly different between patients with BPD or AVD and the "normal" control subjects.  

The brains of the controls seemed to habituate, while those of the patients with BPD did not.  Habituation means that the controls got used to or became accustomed to the awful pictures, and their arousal levels decreased from what it had been after the initial viewing.

If anything, the emotional arousal of patients with BPD actually increased with the repeat viewing.

This finding, if it can be replicated, might seem to indicate that the brains of those with BPD are abnormal in this regard. However, as I have ranted in the past, a difference is not automatically indicative of an abnormality. In fact, it may be a conditioned response that is highly adaptive in particular environments.

In the case of patients with BPD in particular, they invariable grow up in chaotic family environments in which “getting used” to the chaos and not reacting to it when one needs to could be hazaradous to their and their family’s health, as described in my post on Error Management Theory.  If the chaos continues, such individuals need to pay even more attention to it, not less. 

This new research finding fits my ideas about that to a tee.


  1. Sir, I learn something each time I read a post here on your blog but also, each time, I feel "offended" - I suppose is the best word for the way some of your words make me feel. I have a disorder (which I do not care to expose here) and am offended when you refer to clients as those with BPD, for example in this post, and the test subjects without a diagnosis as "normal". Even though you inserted quotation marks around the word it doesn't take away the power of just that one word to invoke feelings of being an outsider, inadequate, damaged goods, labeled, etc. etc. I hope you understand what I'm getting at here. I understand that you, one who does not have such a disorder, cannot possibly examine every single word you use in order to be careful not to offend those who may be "hypersensitive" to such things. I know a lot of clients of the mental health system and we've all agreed that :
    1. There is no such thing as normal, everyone has Something going on, it's just more apparent in us and we're more blessed than most others because we're doing the right things to learn to cope with our disorders.
    2. Many people either fear or disbelieve any such thing as mental illness. These people are not better than us; they are only uneducated on the subject and if they were willing to be educated and accept m.i. as a MEDICAL diagnosis that needs treatment, the stigma of mental illness would most likely all but disappear.
    3. By spreading the word, letting others know when something they said or did was offensive to many who have a mental diagnosis, we are helping ourselves, each other, and those who will come after us.

    I hope my comment did not sound aggressive or angry. That's the problem with all this technology, we don't get to hear the tone of the person's voice who is saying the words to us we are reading.

    God bless you, thank you for a very informative and interesting article.

    1. Hi Cynthia,

      Thanks for your comments.

      Unfortunately, in my defense, those subjects who supposedly have no clear diagnosable disorders are routinely called "normal controls" in all studies in all journals. We do all have to speak the same language, and it gets a bit cumbersome to say "a sample of people with no obvious psychiatric disorders" every time.

      But I definitely appreciate how that might rub you the wrong way!

      Actually, just to make my own position clear, I don't think personality disorders are brain diseases, or diseases at all. As I describe in the post, they are adaptations to a crazy environment, and they make total sense in context. And I agree with you that everybody has their own particular "craziness" (figuratively, not literally speaking).

  2. This post I think nailed it. I always seem to be on high alert. I never understood why I always seem to be in fight or flight mode. This article makes perfect sense to me. I was neglected and abuse as a child. My father had severe PTSD from being a pilot in WW2 and I think he had BPD from an abusive father. I can see how it can be genetic but also the environment is needed. I think BPD is a disability, our brains don't word the way they should from years of abuse and neglect as children. Our brains didn't develop correctly. Every day is a challenge for me. I have found meditation does help. Thank you for helping me to understand better how my mind works.

  3. Chaos?

    This is chaos:

    The DEA sums up Methylphenidate and Amphetamine use this way: “this data means that neither animals nor humans can tell the difference between cocaine, amphetamine or methylphenidate when they are administered the same way at comparable doses. In short, they produce effects that are nearly identical.


    1. Very true, and something I've blogged about already, but I'm not sure what that has to do with this post.

  4. Could be the so-called BPD folks were more resentful of being put through their paces in an institutional environment. Just sayin'.

  5. Borderline Personality Disorder is the most difficult to understand and diagnose mental illnesses. As a consequence there is little awareness of its existence in the general public. If there were greater awareness, more resources would be brought to the table to help these people. I believe the biggest problem is its name. "Borderline" means nothing in helping us understand the condition. I have proposed that we change the name to Faultfinding Personality Disorder based on the most important diagnostic criterion - chronic finding of fault with themselves and others due to their black-and-white thinking which leads to disturbed interpersonal relationships. To back this up I wrote the book "Faultfinders: The impact of borderline personality disorder." I explained the condition using examples of numerous famous people to make the symptoms memorable. I would be interested to hear what others think about a possible name change.