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Implications ofImplications of

Recent Neurobiological Recent Neurobiological

Findings for the Psychotherapy Findings for the Psychotherapy

of Borderline Personality of Borderline Personality

DisorderDisorder

Glen O. Gabbard, M.D.

Brown Foundation Chair of Psychoanalysis

and Professor of Psychiatry

Baylor College of Medicine

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NeuroplasticityNeuroplasticity

Psychotherapy changes the brain.

Mind is the activity of the brain, but all aspects of experience cannot be reduced to the causal consequences of brain mechanisms alone.

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Self-Directed Neuroplasticity

Contemporary physics departs from classical physics by supporting the notion that intrinsic mental contents – feeling, knowing, and effort– are primary causal factors.

The conscious act of willfully altering the mode by which experience is processed can change the cerebral mechanisms used.

- Schwartz et al 2005

Psychological treatmentof disorders caused by

neurobiological phenomena can be

a reasonable and realistic goal

- Schwartz et al 2005

The prefrontal cortex appears to be one brain area

activated in studies on self-directed

regulation of emotional response

“The aim of the talking cure…

from the neurobiological point of viewis to extendthe functional

sphere of influenceof the prefrontal lobes.”

-Solms and Turnbull 2002

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Tourette’s Syndrome

A disorder of self-regulation

Chronic motor and vocal tics

“Premonitory urges” involve sensorimotor impulses that are suppressible, but not indefinitely

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Theory of Compensatory Effects

Tic Suppression

����

Activates Frontal Cortex

����

Plastic Response in Frontal Cortex

���� ����

Smaller Volumes Larger Volumes

���� ����

More Symptoms Fewer Symptoms

- Peterson et al., Arch Gen Psych 1998

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BORDERLINE

PERSONALITY

DISORDER

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The Role of the Amygdala

The amygdala increases vigilance

The amygdala facilitates an individual’s evaluation of threat or danger

BPD patients with histories of childhood trauma have been shown to have hyperreactive amygdalar responses

- Herpertz et al., Biol Psych 50: 292-298, 2001

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Hippocampus

Thalamus

AmygdalaMedial PrefrontalCortex

Hypothalamus Orbital PrefrontalCortex

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Response to Facial Expressions

BPD patients show significantly greater left amygdalar activation to facial expressions compared with normal controls

BPD patients attribute negative qualities to neutral faces

- Donegan et al 2003

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Amygdala Hyperreactivity (Ekman Faces)

NC = normal control. - Donegan et al. Biol Psych 2003;54:1284

Activation map showing regions in the amygdala slice in which activation exceeded the criterion threshold level of P<0.005 for the NC and BPD groups for each of the 4 facial expressions.

Neutral Happy

Sad Fearful

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Response to Facial Expressions(cont.)

A hyperactive amygdala may be involved in

the predisposition to be hypervigilant and

overreactive to relatively benign emotional expressions

Misreading neutral faces is clearly related

to the transference misreadings that occur

in psychotherapy and the creation of “bad

object” experiences

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MR Volumetrics: Orbitofrontal Cortex in BPD

- van Elst et al., Biol Psych 2003;54:163

13.7910.5 12.12

10.59

8

9

10

11

12

13

14

15

= HC = BPD

L R Control BPD

L

8

10111213141516

9

Vo

lum

e (c

m3 )

Vo

lum

e (c

m3 )

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AMYGDALA

REFLEXIVE/AUTOMATIC PROCESSES:

“BOTTOM-UP” REGULATION

“Bottom-Up” Regulation of Emotion

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AMYGDALA

PREFRONTAL CORTEX:“TOP-DOWN” REGULATION

REFLEXIVE/AUTOMATIC PROCESSES:

“BOTTOM-UP” REGULATION

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The Frontolimbic Network

The frontolimbic network appears to be central to the emotional dysregulation in BPD

This network consists of:

anterior cingulate cortex (ACC)

orbitofrontal cortex (OFC)

dorsolateral prefrontal cortex (DPC)

hippocampus

amygdala

- Schmahl and Bremner, J Psych Res 40:419-427, 2006

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The Frontolimbic Network (cont.)

Same brain areas are also involved in dysfunctional serotonergic transmission, associated with impulsive aggression in BPD

ACC may be viewed as the brain region mediating emotional control, and studies show that it is deactivated in response to stressful stimuli in BPD

ACC dysfunction is probably a key factor in the emotional dysregulation seen in BPD

--Schmahl and Herpertz, J Psych Res 41:419-427, 2006

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Frontolimbic Inhibitory Function

BPD patients were asked to push a button for words in standard font but not for italicized words.

BPD patients were more impulsive than controls, particularly when the italicized words were negative.

In contrast to controls, BPD subjects showed � amygdalar reaction and � activity in subgenual cingulate and in medial OFC.

- Silbersweig et al.: Am J Psych 164:1832-1841, 2007

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Frontolimbic Inhibitory Function(cont.)

Also in response to negative words, BPD subjects showed � activity in the dorsal ACC.

Hence even though they were not able to exercise impulse control, they were aware they had to devote other resources to monitoring it.

- Silbersweig et al.: Am J Psych 164:1832-1841, 2007

Neuroimaging data of adult BPD patients suggest that amygdalar hypersensitivity and emotional dysregulation may be related to specific

dysfunctionsin the prefrontal cortex

and the ACC

-Herpertz et al., Biol Psych 50: 292-298, 2001-Donegan et al., Biol Psych 54: 1284-1293,2003-Schmahl et al., Biol Psych 54: 142-151, 2003

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Self-Regulation of Emotion

Willful mental activity is particularly

critical to affect regulation.

The mental action of reflection, mindful

awareness, or mentalization modulate the

activity of the prefrontal cortex and ACC.

Observing and modulating one’s own

emotional states affects the brain in a way

that is concordant with contemporary

physics.

- Schwartz et al 2005

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Implications

Therapeutic change takes effort.

Mental resources must be directed away from lower level limbic responses and toward higher level prefrontal functions.

Self-directed neuroplasticity research suggests that the way a person directs attention will affect both the state of the brain and the experiential state.

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A Common Factor in DBT and MBT

Empirically-supported therapies for BPD,

like dialectical behavior therapy (DBT) and

mentalization-based therapy (MBT), both

feature self-reflective, mindfulness-

promoting techniques

Ochsner et al (2002) have shown that

actively rethinking or reappraising feelings

causes prefrontal activation that modulates

limbic-based negative feelings such as fear.

T R A N S F E R E N C ET R A N S F E R E N C E

PHENOMENAPHENOMENA

Misreading of neutral facial expressions is only part of the total picture

Women who are diagnosed as BPD actually can be more accurate in the labeling of fearful facial expressions than controls.

- Wagner & Linehan, J Personality Disorders 13:329-344, 1999

Heightened Emotional SensitivityHeightened Emotional SensitivityHeightened Emotional SensitivityHeightened Emotional SensitivityHeightened Emotional SensitivityHeightened Emotional SensitivityHeightened Emotional SensitivityHeightened Emotional Sensitivity

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Heightened Emotional Sensitivity (cont.)

Morphing of facial expressions is needed to accurately assess the capacity of BPD patients to respond to emotional expressions.

Faces change gradually and monotonically from neutral to prototypical emotional expressions at maximum intensity.

Allows assessment of how intense a facial expression must be before accurately recognized.

Lynch et al, Emotion 4:647-655, 2006 -

Morphed Fear Faces – Within Person

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Heightened Emotional Sensitivity (cont.)

20 BPD subjects and 20 normal controls were compared on the morphing test.

BPD patients correctly identified facial affect at an earlier stage than controls.

Lynch et al, Emotion 4:647-655, 2006

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Heightened Emotional Sensitivity (cont.)

BPD subjects were more sensitive than healthy controls in identifying the emotional expressions in general.

Their results support the contention that heightened emotional sensitivity might be a core feature of BPD.

Findings are consistent with emotional dysregulation as central to BPD—these patients overreact to relatively minor emotional expressions and interpersonal cues.

Lynch et al, Emotion 4:647-655, 2006

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Reading the Mind in the Eyes Test

(RMET)

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Reading Faces & BPD

30 patients with BPD compared with 25 healthy controls using RMET

BPD group performed significantly better than healthy controls.

- Fertuck et al, Psychological Medicine, 2009

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Reading Faces & BPD (cont.)

Enhanced performance may be related to greater threat potential perceived in facial stimuli and hypervigilance.

Neutral faces may represent the most ambiguous threat, so there is particular vigilance paid to neutral facial expressions.

BPD subjects do particularly well compared with controls on neutral faces.

-Fertuck et al, Psychological Medicine , 2009

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Reading Faces & BPD (cont.)

Perception of facial expressions is fairly accurate in patients with BPD.

BPD patients have adapted to childhood trauma by assessing moment-to-moment shifts in the emotional state of others as a means of surviving.

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Reading Faces & BPD (cont.)

The problem area for BPD lies in the interpretation of the emotional expression, particularly neutral or ambiguous states.

The main difficulty appears to be assessing whether someone is trustworthy or not—they have difficulty linking trustworthiness with facial expression.

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Reading Trustworthiness

BPD group sees faces as less trustworthy than controls

In contrast to trust, BPDs and controls read fear similarly

BPD group takes longer to judge faces as more trustworthy: also, shows more decision uncertainty

Fertuck et al, Psychological Medicine, 2009

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Paradox in the BPD Field

The so-called “radar” for the therapist’s countertransference reflects the BPD patients heightened capacity to read early changes in facial expressions.

However, co-existing with this capacity are misinterpretations that are quasi-delusional.

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Donegan Subjects on Neutral Faces

“They look like mug shots, like someone who just got arrested”

“They look fake, like a façade—they’re hiding something”

“They look like they are plotting something—untrustworthy”

Donegan, Biological Psychiatry, 2003

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Paradox in the BPD Field (cont.)

Heightened sensitivity may be both accurate and inaccurate.

Accuracy probably varies depending on the state of the attachment relationship, the presence of powerful feelings, and the degree of ambiguity of the facial expression.

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Paradox in the BPD Field (cont.)

Mentalizing resides on a continuum from being accurate at some moments to absent at others.

Mentalizing is intimately linked to the sense of being understood by an attachment figure, and BPD patients have trouble maintaining mentalization in the context of an intense attachment relationship. The attachment system is hypersensitive in BPD.

- Bateman & Fonagy, 2004

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Psychotherapeutic Implications

Clinician needs to be aware that the patient may be accurately tuning in to a not-yet-conscious feeling state in the therapist.

It is also possible that the patient may be misinterpreting and overreacting to a small change in facial expression.

Therapists must be aware of nonverbal communications to patients.

Don’t act “neutral”: be natural! The classical “blank screen” is dead and buried.

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Implications for PsychotherapyThe assumption of malevolence interferes with the therapeutic alliance in BPD.

The therapeutic alliance is an achievement of the therapy with BPD

Transference interpretation is a high-risk, high-gain intervention in BPD

Transference interpretation must be preceded with a solid therapeutic alliance

Gabbard et al, Harv. Rev. of Psych., 1994

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The Role of Intense

Affect States

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Affect and Reason

Affect is a special and powerful element that overrides the capacity to think and reflect.

Strong emotion can stimulate action without the individual taking time to consciously access the stimulus in a reflective manner.

» -- McGaugh 2004; LeDoux 1996

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Overarching sense of self as agent is an integration of a myriad of conscious and unconscious self-representations

Affect-laden transferences reflect the activation of specific unconscious self-representations in interaction with unconscious object-representations

Gabbard 2007

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Overarching sense of self as agent

selfself--

reprepselfself--

reprep

selfself--

reprepselfself--

reprepselfself--

reprep

selfself--

reprepselfself--

reprepselfself--

reprepselfself--

reprep

selfself--

reprepselfself--

reprepselfself--

reprep

selfself--

reprepselfself--

reprepselfself--

reprepselfself--

reprep

selfself--

reprep selfself--

reprep

selfself--

reprep

consciousconscious

unconsciousunconscious

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When conscious circuits are activated all aspects of the self can make a balanced assessment of the situation

Powerful feelings can activate one unconscious circuit linked to one unconscious self-representation

The result is behavior that bypasses the rational processing of the cortex and the more global self of the patient

Gabbard 2007

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Patient may view the behavior retrospectively by saying, “That’s not me. I’m not like that.”

The observing, reflective self can weigh far more variables and view the emotional self-representation as a foreign body

This phenomenon may contribute to a form of temporal splitting.

Gabbard 2007

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Implications for Psychotherapy

“Strike while the iron is cold.” Engage the

patient in retrospective reflective appraisal

of “knee-jerk” emotional reactions.

Focus on alternative perspectives

Help the patient integrate split-off aspects

of the self into an overarching self that

recognizes the self as continuous over time.

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Conclusions

Neurobiology informs psychotherapeutic strategies

Transference is shaped by biology in conjunction with past experience and unconscious internal object relations

Enhanced knowledge of brain mechanisms may hold clues to the therapeutic action of psychotherapy