The Disorder

Some Aspects of the disorder explained

Basics of Emotion Neurobiology
The amygdala is the emotion-processing center and the prefrontal cortex is the brake pedal for the amygdala (the control center for emotions).  People with BPD have an overactive amygdala, experiencing emotions to an infinitely greater degree than the average person, and an underactive prefrontal cortex leading to unregulated emotions.  Their sympathetic, fight or flight, system is on overdrive and they go from zero to sixty on the emotional scale within a few seconds with a slow return to baseline.  Those around them do not understand why their emotions are heightened because their healthy brains do not allow them to experience emotions at this level of intensity.

Impulsivity 
Impulsivity is a hallmark feature of BPD.  When self-injury or drug abuse is involved it is often misconstrued as an intended suicide attempt; however, its purpose is to regulate unbearable emotional states.  Non-suicidal self-injury such as cutting, substance abuse and unsafe sex are some of the ways individuals cope with their emotional pain.  When describing cutting episodes, many say that they do not realize they’ve cut until the episode is over.  The emotional pain is so tremendous that the mind shuts down until it is completely distracted by physical pain.

The Negative Bias & Rejection Sensitivity
People living with bpd have impairment in the evaluation of neutral facial expressions and attribute more negative emotions to such expressions.  A mere neutral facial expression can generate a negative feeling such as disapproval or disgust.  These feelings are taken personally which then leads to emotional instability.

They have an elevated expectation of being rejected and ruminate about this expectation.  When rejection is perceived they react intensely towards it either with extreme anxiety or anger.  This often leads to avoidance of situations that will create rejection, which propagates social isolation.

For example, if Danielle who has BPD is waiting for her friend Hannah to meet her for dinner and Hannah is running late Danielle will begin to think that she is a loser and not worth a friendship.  These feelings will build to an extremely negative point where she may do something impulsive such as drive away recklessly or cut herself.  

Memory Impairment
Areas of the brain responsible for processing emotional stimuli overlap with areas associated with learning and memory.  The limbic system houses areas of the brain including the amygdala and hippocampus.  It supports functions such as emotion, behavior and long-term memory.  Studies of individuals with BPD have shown decreased hippocampal volume, the memory storage area of the brain.  

We have always learned that it is easier to remember something that is tied to an emotion than something that is not.  People with BPD have an elevated susceptibility to attend to and to store emotional information.  Given that people with BPD are often in a negative state of heightened emotions, they tend to remember content tied to these states.  This negative emotional content is more likely to transfer into long-term memory and consolidation, allowing for its better recall.  Unfortunately, the storage of emotional content comes at the expense ofnot storing other non-emotional content.  

For example, Danielle and her brother Nicholas grew up in a loving household where their father always gave them a hug and kiss before he left for work in the morning.  One morning when Danielle (7yrs old) and Nicholas (9yrs old) were eating breakfast before school and their father gets an emergency call from work requiring him to rush out of the house.  Their mother quickly helps him put his coat on and gives him his car keys and he yells goodbye and jets into his car.  Danielle feels rejected and insignificant to her father that day because she did not get a hug and kiss from him.  She ruminates about it all day and interprets this as not being loved by her father.  Nicholas doesn’t think anything about it and by the time they are grown up he has no recollection of the event.  Danielle, now age 20, still recalls that day when dad never said goodbye.  She’ll compile similar negative memories in her life and may even think that her father was never there for her.

Identity Disturbance
There are many different aspects of the self that play a role in identity.  Some of which are the ability to identify our feelings, identify the feelings of others, memory and level of self-esteem.  Individuals with BPD experience alexithymia, which is the inability to identify their own emotions.  The very heightened emotions they express outwardly are unidentifiable inwardly and they often cannot identify the emotions of those they are unintentionally hurting.  They in turn lack the tools to sympathize, converse and apologize.  The memory impairment they experience (explained above) creates a negative life narrative with missing important information.  The aforementioned traits play into having low self-esteem and an overall feeling of worthlessness.

Mentalization 
Peter Fonagy, one of the founders of mentalization, describes it as “the ability to understand others in terms of their thoughts, feelings, wishes and desires.” In other words, it is the ability to reflect on a situation and entertain other viewpoints.  Mentalizing is crucial for successful interpersonal relationships, regulating emotions, building a sense of self and personal security.  In BPD, mentalizing is deficient.

Danielle in the above example is unable to entertain alternative thoughts that may be going on in Hannah’s mind.  Hannah may be thinking about how stressed she is that she cannot make it to dinner on time, how sorry she is for making Danielle wait, how much she is looking forward to having dinner and catching up with Danielle.  Immediately Danielle feels rejected and thinks Hannah does not value her at all and stays with this sentiment without offering herself reflection.

Mentalization based therapy teaches the individual to examine his/her interpretation of the scenario based on external features and then generate possibilities about the internal states of mind.  It slows down the individual and encourages him to be mindful of his assumptions.

Shame 
Shame is one of the major characteristics of BPD.  It is defined as a painful feeling of humiliation or distress caused by the consciousness of wrong or foolish behavior.  It differs from guilt in that it is a feeling of the whole self and guilt is a feeling about a situation.  Individuals with BPD feel shame most of the time for no identifiable reason.  Some argue that shame is the underlying feeling behind chronic suicidality, self-injurious behavior, anger and impulsivity.  It can lead to avoiding social situations or other situations where it may be provoked.

Sleep Disturbance
Individuals with BPD have a different sleep structure than healthy individuals.  They have decreased REM latency and total sleep, more stage I sleep and less stage IV sleep.  Individuals themselves report reduced total sleep quality and sleep time, decreased sleep efficiency, feeling significantly more exhausted and a worse evening mood.  Studies also show that they suffer a greater rate of nightmares, higher levels of dream anxiety and more disturbed sleep than normal individuals.

Functional Impairments
Studies have shown significant impairment across the full range of traditional neuropsychological testing which includes attention, cognitive flexibility, learning and memory, planning, processing speed and visuo-spatial abilities.  Overall the level of intelligence has remained equal to those without BPD.  Individuals with BPD have trouble making a decision when there is a scenario with many options.  It becomes easier to make decisions when there are few options without any ambiguity.  The orbitofrontal cortex and the anterior cingulate cortex are areas of the brain responsible for decision-making and they have found to be impaired in those with BPD.

 

Misconceptions

They are manipulative

The reality is that the individual is engulfed in misery and pain and will do anything out of desperation to anesthetize his feelings, including resorting to intolerable behaviors.

BPD can’t be diagnosed in adolescence or childhood

The major problem is that BPD is often diagnosed too late, after the individual has made detrimental life decisions. Almost all individuals exhibit signs of BPD by adolescence. It can be seen in infants who have sleep disturbances and children who have temper tantrums that are disproportionately longer and more frequent than the average child. Recently articles have been published supporting the case that which BPD can be diagnosed before the age of 18.

All BPD patients have been abused

Although a history of abuse can lead to the development of BPD, this is not always the case. Parents often feel shame about their child’s diagnosis because of this. There simply have not been enough studies proving the other reasons for the development of BPD. There are some genetic studies attempting to identify the BPD gene that are currently underway.

They are untreatable or treatment resistant

There are effective treatments such as DBT, Mentalization based thereapy (MBT) and Transference Focused Therapy (TFT) that when given by trained clinicians have been proven to be effective. In addition to effective treatment given by clinicians, family members play a huge role in recovery. This is an interpersonal issue and when families learn to understand the disorder and create a more validating environment individuals become less dysregulated and are more likely to stay in therapy.

Medications are effective

Although it is worth trying various medications to manage symptoms of BPD, such as anxiety and depression, there have not been any large studies proving that medications are helpful. Despite this most individuals are on multiple unhelpful medications and suffer from their side effects.