Borderline Hyper-reactivity: Compared to What?

One of my complaints about the research literature on the so called “hyper-reactivity” of patients with borderline personality disorder (BPD) is that the authors of such studies almost always look at the quality and frequency of their subjects’ responses without ever looking at what they are responding to.  Since mood instability is the most central part of the definition of the disorder, of course they will have more reactions. By definition, they’ve been selected for it!

 

Two recent studies show that patients with BPD really don’t seem as different from others as one might expect. They both provide strong evidence for my point of view. One showed that the specific reactions to interpersonally threatening stimuli of patients with BPD  is not all that different from those of anybody else.  It looked at skin conductance responses (SCR, a measure of stress) in patients and healthy controls.  The second investigated whether or not patients with other psychiatric disorders responded differently. They found that they all sort of responded the same, in spite of the fact that - once again  - the source and severity of the environmental events which triggered the patients was ignored.

Here’s some descriptions from the study abstracts.

1.   Hillmann K; Mancke F; Herpertz SC; Jungkunz M; Olsson A; Haaker J; Bertsch   K. Psychopathology. 53(2):84-94, 2020. Intact Classical Fear Conditioning to Interpersonally Threatening Stimuli in Borderline Personality Disorder.

 

Threat hypersensitivity is regarded as a central mechanism of deficient emotion regulation, a core feature of patients with borderline personality disorder (BPD). In this study, patients with BPD showed larger conditioned prolonged conditioned skin conductance responses (SCR) (a measure of stress) and subjective stress and expectancy ratings  to interpersonally non-threatening and neutral than interpersonally threatening stimuli, while interpersonally threatening stimuli elicited higher SCR compared to non-threatening or neutral stimuli in healthy controls. 

While the overall the results suggest no alterations in fear conditioning to generally aversive stimuli in BPD, it’s quite interesting than when someone in the environment is non threatening, patients with BPD react with MORE stress. One possible explanation: the people around them most of the time are more likely to attack them when most  other people would have let their guard down.

2.  Kockler TD; Santangelo PS; Limberger MF; Bohus M; Ebner-Priemer UW, Specific or transdiagnostic? The occurrence of emotions and their association with distress in the daily life of patients with borderline personality disorder compared to clinical and healthy controls.
Psychiatry Research 284, 11262, 2020).

 The authors wanted to see if hyper-reactivity to stress was specific to BPD or was seen as much in other disorders. Using e-diaries, they compared patients with BPD, normal controls, patients with bulimia, and those with PTSD. The majority of the comparisons (anxiety, sadness, shame, disgust, jealousy, guilt, interest) revealed transdiagnostic patterns, which means that the same reactivity was seen in the other disorders. The only major exception was that patients with BPD exhibited anger more frequently than any of the clinical groups or in healthy control. 

As mentioned, nothing was looked at concerning what the anger was about. So maybe anyone would be angry if exposed to whatever it was the patients with BPD had been exposed to. 

Words Do Matter in Psychiatry

I was pleased to see that in the June 2018 issue of one of the newspapers for psychiatrists, Clinical Psychiatry News, a psychiatrist by the name of Carl T. Bell wrote about something I have been harping about in this blog and elsewhere for years: the sloppy use of psychiatric terminology by both the public and by many psychiatrists themselves.

Glad to know I’m not the only one who has noticed this.

He brings up three examples: the use of the words (two of which also have a common meaning separate from the corresponding terms in psychiatry): traumatized, depressed, and bipolar.

Colleagues of his had used the word traumatized as something that happened to a person who was the subject of a statement by another person that has come to be known as a “microaggression.” A microaggression is defined as “a statement, action, or incident regarded as an instance of indirect, subtle, or unintentional discrimination against members of a marginalized group such as a racial or ethnic minority.” 

Worrying about that sort of thing has become endemic on college campuses recently. Especially if it unintentional, the result of the big ado is a communication to individuals that they are so fragile and vulnerable that they can’t handle anything. It also has led to a suppression of free speech.

As far as I know, there has never been an example of a microaggression, or even a direct verbal insult, in and by itself leading anyone to develop post traumatic stress disorder (PTSD). According to Dr. Bell, being stressed by something like that, or by your boss chewing you out, is a far cry from being traumatized. Being distressed by something like the death of a parent is a little worse. It can come up from time to time, like on the anniversary of the death. However, in both of these cases, unlike in PTSD, “the mind is able to make peace with the reality…and life goes on.

“Traumatic stress, on the other hand,” he adds, “is an event so painful and disruptive that it runs the risk of breaking the mind’s ability to make peace with the event…[and it] disrupts or destroys normal psychic life.”

I would add that if everyone around you treats you like you are so fragile that the slightest stress will do that, you start to believe it even though you probably aren’t that fragile at all. And if you feel like that, you are probably not going to take measures to actively oppose and undermine things like racism, sexism, and homophobia. If enough people think like that, it is paradoxically a great boon to racists, sexists, and homophobes everywhere.

I’ve already covered the misuse of the term depression in my post of November 24, 2015, Depression is a Symptom, not a Psychiatric Disorder. Major depression is a clinical condition has many physical symptoms and is something that can be quite disabling, while being unhappy, sad, grieving or even demoralized is not the same thing at all. The latter conditions do not respond to antidepressants in the least, but researchers doing current studies on antidepressant efficacy have become very sloppy and often do not exclude the latter people as they should.

Bell then addresses how the term “bipolar” is creeping into common usage to cover things such as being moody and having difficulty regulating one's moods and having a bad temper (especially in kids, I might add). For maybe thirty minutes or an hour. And many psychiatrists just take patients at their word when they misuse the term, and prescribe unnecessary and ineffective mood stabilizers.

In that vein, another article in the April issue of the same newspaper quoting a Gabrielle Carson M.S. talks about the issue of tantrums in children. It advocates investigating the child’s symptomatology to rule out bipolar and other mental disorders, as well as clearly behavioral problems like so-called disruptive mood dysregulation disorder, ADHD, and oppositional defiant disorder. 

The only mention of environmental factors that might lead to the tantrums is a quick and superficial reference to child abuse and school bullying. But the article says absolutely nothing about the far most common cause of frequent tantrums by children (as discussed by child psychologist and columnist John Rosemond as well as other people who actually look at what goes on in the child’s home): problematic parenting practices such as acting like a friend to your kids instead an authority figure, letting them make decisions that should be made by the adults, compulsive yelling or lecturing, and inconsistency in administering discipline.

Researchers Aren't Wasting Time Looking for Cures for Alzheimer's Disease or Schizophrenia

As I did on my posts of November 30, 2011,  October 2, 2012, and September 17, 2013, it’s once again time to look over the highlights of the latest issue of one of my two favorite medical journals, Duh! and No Sh*t, Sherlock. Let’s take a look at the unsurprising findings published in the latest issue of Duh! My comments in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

9/13/13. Effects of Child Abuse Can Carry Over, Study Finds.

Researchers with the National Academy of Sciences reported Thursday that the damaging consequences of abuse can not only reshape a child’s brain, but can last a lifetime. Untreated, the effects of child abuse and neglect, the researchers found, can profoundly influence a child’s physical and mental health, their ability to control emotions and impulses, their achievement in school, and the relationships they form as children and as adults.

Cognitive behavioral therapists are all up in arms in reaction to this, thoroughly annoyed that the psychoanalysts were right about some things.

9/16/13.  Teens Who Text About Fighting, Drug Use More Likely To Engage In Those Behaviors.

HealthDay (9/14, Preidt) reported that research published in the Journal of Abnormal Child Psychology suggests that “teens who text about bad behaviors such as drug use or fighting are more likely to actually engage in those behaviors.” Researchers examined the text messages of more than 170 ninth-graders. Their behaviors were rated by their teachers, parents, and fellow students. The investigators “found a strong link between antisocial text messages and higher ratings of antisocial and aggressive behavior at the end of the school year.”

If they were real sociopaths, they wouldn’t have to brag about it.

 

9/27/13. Common Pain Relievers May Reduce Depression In Individuals With Osteoarthritis.

Reuters (9/27, Doyle) reports that research published in the American Journal of Medicine suggests that common pain relievers may reduce both pain and depression among individuals with osteoarthritis. Investigators came to this conclusion after looking at data from five trials that included approximately 1,500 patients.

Pain causes people unhappiness??  I always thought pain was something that causes unremitting happiness and celebration.

10/21/13. Stalking May Cause Psychological Distress.

HealthDay (10/19, Dallas) reported that, according to a study published online in the journal Social Science Quarterly, “women who are the victims of stalkers are up to three times more likely than their peers to experience psychological distress.” Researchers arrived at this conclusion after examining data “compiled on over 8,100 women from three major surveys.”

And here I thought stalkers were spreading joy wherever they went.

2/27/14.  Suicide Attempts Early in Life Signal Long-Term Social, Health Problems, Study Finds

Young people who attempt suicide are not only more likely to have persistent psychiatric problems as they approach midlife than non-attempters, but they are also more likely to have physical health problems, engage in violence, and need more social supports as they age. These are key findings from a study by led by Sidra Goldman-Mellor, Ph.D., and colleagues at Duke University and several other institutions and reported in JAMA Psychiatry.

The best predictor of future behavior is past behavior?  Who knew?

2/27/14. Study: Stigma Associated With Mental Illness May Prevent Many People From Seeking Care.

HealthDay (2/27) reports that research published in Psychological Medicine suggests that “the stigma often associated with mental illness prevents many people from getting the care they need.” Investigators looked at data from 144 studies that included a total of approximately 90,000 people. The researchers found that “stigma ranked as the fourth highest of 10 barriers to care.” The investigators also found that, “aside from the stigma of using mental health services or being treated for mental illness, the participants also reported feelings of shame and embarrassment as reasons for not seeking care.”

Caring about what other people think?  Worrying about your reputation?  Who does THAT?

3/17/14. Stress May Impact Kid's Health, Well- Being  

HealthDay (3/15, Preidt) reported that according to research presented at the American Psychosomatic Society’s annual meeting, “stressful events can have an almost immediate impact on children’s health and well-being.” After analyzing data on some 96,000 US children, researchers also found that youngsters “who experienced three or more stressful events were six times more likely to have physical or mental health problems or a learning disorder than those who had no stressful experiences.”

Nonsense.  Learning how to react to constant threats to your well being builds character!

4/8/14. Study: Physician appointment availability greater with private insurance than Medicaid.

Reuters (4/8, Seaman) reports on a new study, published in the current edition of JAMA Internal Medicine, which shows the availability of physicians varies depending on a patient’s insurance coverage. Researchers, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, found they were able to book appointments 85% of the time when claiming private insurance, compared to just 58% when they claimed to be covered by Medicaid.

Oh come on. Doctors absolutely hate to make money.

4/14/14. Paternal Alcoholism Tied To Family Conflict.

Reuters (4/11, Bond) reported that according to a study published online March 15 in the journal Addictive Behaviors, families in which the father had a problem with alcohol appeared to experience increased levels of conflict. However, treating men for alcoholism may result in an improved home life for their children.

Gee, and I thought drug addiction was a symptom of family harmony.

4/22/14.  False-Positive Mammograms Linked To Increased, But Temporary, Anxiety.

The Los Angeles Times (4/22, Kaplan) “Science Now” blog reports that in a study published in JAMA Internal Medicine, investigators “examined data from a large clinical trial of digital mammography and concluded that false-positives produced a ‘significant increase in anxiety,’ though it was only temporary.”

       

People get nervous if they think they might die. Really?

5/1/14. Effects of Recurrent Violence on Post-traumatic Stress Disorder and Severe Distress in Conflict-affected Timor-Leste: a 6-year longitudinal study

Silove D, et al. – Recurrent violence resulted in a major increase in post–traumatic stress disorder and severe distress in a community previously exposed to mass conflict. Poverty, ongoing community tensions, and persisting feelings of injustice contributed to mental disorders. The findings underscore the importance of preventing recurrent violence, alleviating poverty, and addressing injustices in countries emerging from conflict.

So what does trauma have to do with PTSD anyway?

More Surprising Findings from the Psychiatry Literature

As we did on my posts of November 30, 2011 and October 2, 2012, it’s once again time to look over the highlights of the latest issues of my two favorite medical journals, Duh! and No Sh*t, Sherlock. 

As I pointed out in those posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already thought to be true but have yet to be "proven"?  Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

So, we have a lot of academics weighing in with studies on the obvious. Literally weighing in. Since academic promotions are often based on the quantity of papers, rather than their quality, schools might measure faculty members' progress towards tenure by calculating the physical weight of the paper on which their authored articles have been written. 

If Albert Einstein had only published his two papers on relativity - which literally changed the entire field of physics forever - that obviously would not have been anywhere near enough for him to get tenure at most universities these days.

So here we go with more fantastic additions to our knowledge base.

 

Early Drinking Associated With Problem Drinking Later

MedPage Today (8/16, Petrochko) reports, "Students who started drinking and getting drunk at an early age were more likely to engage in frequent heavy drinking and associated problems by senior year of college," according to a study published online Aug. 15 in the journal Alcoholism: Clinical and Experimental Research. "A longitudinal analysis of incoming college freshmen showed a significant association not only between younger drinking age and heavy drinking, but also with difficulties in work and school, blackouts, vomiting, and other problems by senior year (P<0.001 for all)," researchers reported.

So self destructive behavior has its roots in childhood experiences, eh?  Someone please tell the psychoanalysts.

And on a related note:

Youth With Conduct Disorder More Likely to Abuse Substances

5/15/13.   A longitudinal study of youth with and without conduct disorder (CD) finds that the former are significantly more likely to abuse substances. The findings are published in the May Journal of the American Academy of Child and Adolescent Psychiatry. Researchers from the University of Colorado prospectively followed 1,165 community-dwelling adolescents without CD, 194 youth in the community with CD, and 268 youth who were in treatment for CD. They were re-interviewed during young adulthood, and self-reports on age of substance initiation for 10 substance classes were analyzed.

Gee, I wonder if family problems and adverse childhood environments lead to both antisocial behavior AND substance abuse? That just never occurred to me before. 

Depression, Mania In Bipolar Disorder Have Differential Social Adjustment Effects

1/23/12.  Medwire (1/23, Cowen) reports, "Results from a UK study show that depression and mania symptoms have specific and differential effects on social adjustment in patients with bipolar disorder (BD). Richard Morriss (University of Nottingham) and team found that depression symptoms have a negative effect on performance and interpersonal behavior, while mania symptoms increase interpersonal friction."

And to think that I used to be under the impression that other people would react to hyperactive, impulsive, hypersexual people in exactly the same way as they would to someone who doesn’t even want to get out of bed or have sex with someone lying naked in the bed next to them.

High Doses of Opioids May Impair Driving

Drivers taking 20 mg of morphine or more per day, or the equivalent, are up to 42% more likely to be involved in road trauma than drivers taking the lowest doses of opioids, according to a new study from the Keenan Research Center of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.

Higher doses of intoxicants lead to more impairment than lower doses?  Who knew?

Anger Due To Delusions May Explain Violent Behavior In Patients With Psychosis

In print and in its "Well" blog, the New York Times (3/11/13) reports that "a new study finds that anger, coupled with psychotic delusions, may be the most significant factor in violence committed by people with mental illness." Medwire (3/12, Piper) reports, "Anger due to delusions appears to be a key factor explaining violent behavior in patients with acute psychosis," according to the results of the 458-patient East London First Episode Psychosis Study published online March 6 in JAMA Psychiatry.  

So people with paranoid delusions that make them feel angry or threatened are more likely to become violent than when they are not experiencing those reactions. So are such people actually psychotic if they act just like everyone else would?

Handling Stress Poorly May Increase Long-Term Risk For Anxiety/Mood Disorders

USA Today (4/4/13) reports that handling "stress poorly...may put you at greater risk for anxiety disorders and other mental health issues 10 years later," according to a study published online in the journal Psychological Science. Researchers from the University of California-Irvine "analyzed data on 711 men and women, ages 25 to 74, who were interviewed two times 10 years apart." Investigators found that "people who responded to stress with more anxiety and sadness than the average person were much more likely to have self-reported anxiety/mood disorders and psychological distress 10 years later."

Oh I get it now! Anxiety is caused by stress. That’s a remarkable insight.

And on a related note:

Association Between Mood and Alcoholism

The Los Angeles Times (5/2/13) A study that was published May 1 in JAMA Psychiatry, found that individuals "who drank 'to alleviate mood symptoms' were three times more likely to become dependent on alcohol than were those who did not use alcohol to calm themselves down or improve their mood."

And mood symptoms are also related to stress, leading to abuse of a psychoactive substance!?!  Even more remarkable.

.................

And we also just learned that actively trying to solve problems rather than just ignoring them is the better way to go. Now that’s counter-intuitive:

Small Study: Way Of Dealing With Emotions Linked To Anxiety Levels

The Time (5/13/14) "Healthland" blog reports, "When faced with a challenge, whether you deny the problems it poses or dive in to solve them in a positive way may determine how much anxiety you feel overall," according to research published in Emotion. The investigators "found that the participants who regularly reframed what was happening to them to view their situation in a better light reported less severe anxiety than the participants who suppressed their emotions in trying situations."

And finally, the question of whether or not the prospect of dying or of someone you love dying leads to psychological distress has at long last been settled by two recent studies.

Parents of Children with Cancer Show High Psychological Distress

5/17/13. A group of researchers associated with several pediatric oncology treatment facilities has published one of the first studies to describe the experience of distress in parents of children with advanced cancer. The researchers found that psycho­logical distress was associated with par­ent perceptions of prognosis, goals of therapy, their child's symptoms/suffer­ing, and financial hardship.

 

   Anxiety May Be Common Among Cancer Patients, Spouses

7/12/13.  The New York Times (7/12, Hoffman) “Well” blog reports that an analysis published in the Lancet Oncology indicates that “within two years of a cancer diagnosis, the pervasiveness of depression in patients and their spouses tends to drop back to roughly the same levels as in the general population, only to be replaced by another mind-demon: anxiety, which can even intensify as time passes.”