Molly Knight Raskin
Scientific American Mind, July/August 2010
Four years ago Amanda Wang, then 27 years old, was at a rehearsal dinner for a close friend. At the start of the evening, she felt content, eager to enjoy the wedding festivities. But shortly after she sat down to dinner, she was struck by “a tidal wave” of negative emotions. Her mind began to race with disturbing thoughts about her own marriage, which was unstable, and feelings of self-loathing. Suddenly, Wang says, it was as if someone had draped a heavy cloth over her, suffocating her and cutting her off from the conversation. Overcome by anxiety and dread, she excused herself from the dinner table and escaped to the bathroom. Desperate to dull her feelings, she removed her belt, tied it around her neck and pulled it tight to stop herself from breathing. She performed this act several times, until the pain offered her some relief from her emotions. After about 10 minutes, she returned to the table, feeling much better.
At the time, Wang felt she was the only person in the world who battled such extreme mood swings—being content one moment and nearly suicidal the next—and who harmed herself to cope with them. “Self-harm was one of the things that I did to myself to stop feeling crazy, to stop all the arguments in my head, the edginess and anxiety,” she says.
But the edginess kept coming back, and just three months later, struggling with suicidal urges, she checked herself into the Payne Whitney Clinic of New York–Presbyterian/Weill Cornell. There an astute social worker studied notes penned by doctors and read interviews with Wang’s friends and family—and delivered the diagnosis that Wang believes saved her life: borderline personality disorder (BPD). Wang and other BPD patients suffer from pervasive instability in mood, relationships and behavior. Partly as a way to cope with their internal chaos, people with BPD may impulsively quit their job, abruptly break off relationships or, like Wang, flirt with suicide.
Because those afflicted display a disparate and variable set of symptoms, even trained mental health professionals can miss the diagnosis or attribute the behaviors to some other cause. What makes diagnosis even trickier is that BPD patients often also suffer from other psychiatric problems, such as depression, bipolar disorder, substance abuse and eating disorders.
Despite such complexity, professionals have identified up to 14 million Americans as having BPD, more than are afflicted with either bipolar disorder or schizophrenia. Its sufferers are among the most likely to injure themselves and to commit suicide; about 10 percent of patients take their own lives. Individuals with BPD also flock to doctors more readily than people with other psychiatric illnesses, occupying fully one fifth of the beds in psychiatric wards, thereby constituting a major public health problem.
In the past scientists and many clinicians viewed the more audacious symptoms of BPD—such as angry outbursts or experiments with self-harm—as willful efforts to manipulate others or attract attention. But in recent years biologists have been looking deeper at the psychological and neurological causes of BPD and have sketched a radically different picture of the ailment. BPD patients do not choose to act the way they do; they are buffeted by a combination of unconscious processes—an unusual tendency to pick up on the subtle facial expressions of others, coupled with hyperactive emotional responses. In addition, a brain region that helps to guide people amicably through social scenarios seems to malfunction in BPD sufferers, an impairment that may add to their insecurity in relationships.
These findings establish BPD’s credentials as a brain disease. The work also has inspired more effective therapies, based on perceptual and emotional underpinnings of the disorder. Psychotherapy for BPD is now enabling patients to overcome an illness that has long been viewed as a life sentence. “This is a disorder that everyone, for a long time, said was untreatable,” says psychiatrist John Gunderson of Harvard Medical School and McLean Hospital. “Today our research shows that when treated properly, BPD is actually a good-prognosis diagnosis.”
Branded Borderline
In the 1930s American psychoanalyst Adolf Stern first coined the term “borderline” to describe patients who fell short of complete psychosis (experiencing a total break with reality) but were emotionally fragile and irrationally sensitive in social situations. In the two decades that followed, clinicians kept encountering patients with similar difficulties, clustering them under titles such as “borderline syndrome” and “borderline personality organization.” Despite its repeated use, the “borderline” label remained vague, considered by many to be a wastebasket diagnosis for people with severe symptoms who did not fit any clear diagnostic category.
As a young resident in the 1960s, Gunderson was nonetheless drawn to this somewhat eclectic group of patients, seeking to better define what ailed them. He was partly driven by the challenge of treating a patient population that many of his colleagues deemed hopeless and irritating. These patients were so exquisitely sensitive in their relationships that they often abruptly terminated therapy, exploded with anger at their clinicians, and even sued them (or threatened to) for perceived slights, abandonment or betrayal. At the same time, they could often be charming, bright and interesting. This Jekyll and Hyde nature fascinated Gunderson, whose roster of BPD patients kept growing.
In 1975 he and psychologist Margaret Singer of the University of California, Berkeley, published a seminal paper outlining the nine defining symptoms of BPD [see box above]. In 1980 BPD became a bona fide psychiatric diagnosis, gaining entry into the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III).
BPD patients commonly suffer from three core difficulties: emotional instability, impulsive behavior and disturbed interpersonal relationships. The emotional storms of people with BPD are not only intense, they are frequent. The cause of these ups and downs is not always apparent to others or easy for people with the disorder to explain. Sometimes a perceived slight—something as minor as a raised eyebrow— can trigger a hemorrhaging of emotion—fear and loneliness, perhaps, or anger and anxiety. The person might be aware that they are overreacting, but the emotions are too forceful for them to control.
Psychiatrist Frank Yeomans of Weill Cornell Medical College says he has been a few minutes late to an appointment only to have a patient storm out of his office, accusing him of hating and neglecting him or her. Once a male patient shared a touching story with Yeomans about his upbringing in an impoverished home. Yeomans recalls being moved to tears, but the patient responded to his sympathy with, “You’re mocking me.” To calm themselves, such patients often act impulsively, making rash decisions and indulging in behaviors such as sub- stance abuse, binge eating, compulsive shopping or, more disturbingly, self-injury. Deliberate self- harm seems to relieve emotional agony in part by the distraction of physical pain and perhaps through the release of natural painkilling opiates.
BPD shares some features with bipolar disorder, for which it is frequently mistaken, but unlike bipolar disorder, BPD does not lead to lengthy cycles of highs and lows. Instead it causes more rapid mood swings. In less than 24 hours, people with BPD can experience euphoria, suicidal depression and everything in between. BPD is also characterized by a disturbing, but fascinating, dual nature: when people with the disorder are not experiencing flagrant symptoms, they often appear highly functional. “You could meet a patient with BPD in a social setting and not have an inkling that the patient had a major psychiatric disorder,” says psychiatrist Glen O. Gabbard of the Baylor College of Medicine. “The very next day the same patient could appear in an emergency room in a suicidal crisis and require hospitalization.”
For most of the 20th century, the prevailing wisdom held that personality disorders were the result of life experience. For BPD, the offending experience was thought to be early childhood trauma. But although people with BPD have often endured traumatic events— 40 to 71 percent of inpatients report childhood sexual abuse— childhood trauma can have diverse effects on the psyche. Studying BPD through the lens of abuse did not help psychologists get a handle on the disorder. By the 1990s researchers were seeking to capture the core psychological abnormalities of patients by investigating them directly and by peering inside their brains.
Emotion Overload
Specifically, scientists wanted to better understand the three hallmarks of BPD: emotional instability, impulsive aggression and interpersonal chaos. Why do people with BPD have so many more emotional flare-ups than healthy people do? And when they feel upset, why do they act out impulsively?
In 2006 psychologist Thomas R. Lynch, then at Duke University, and his colleagues found a clue in the reading of facial expressions. The researchers asked 20 adults with BPD and 20 mentally healthy people to watch a computer-generated face change from neutral to emotional. They told subjects to stop the changing image the moment they had identified the emotion. On average, the people with BPD correctly recognized both the unpleasant expressions and the happy faces at a much earlier stage than the other participants did. The results suggest that BPD patients are hyperaware of even subtly emotive faces—problematic in people who are intensely reactive to other people’s moods. So, for example, a hint of boredom or annoyance on a person’s face that most people would not notice might produce anger or fears of abandonment in a person with BPD. Conversely, someone with BPD might see a happy expression as a sign of love and react with inappropriate passion, leading to the whirlwind, stormy romances that rock the lives of people with BPD.
A recent brain-imaging study suggests why these patients are so socially sensitive and moody. In 2009 psychiatrist Harold W. Koenigsberg and his colleagues at the Mount Sinai School of Medicine used functional magnetic resonance imaging to record activity in the brains of 19 BPD patients and 17 mentally healthy individuals as the subjects examined photographs of people crying, smiling, acting violently and making sexual gestures. The researchers found that the unpleasant images (a man grabbing a woman’s neck, say, or a woman crying) elicited much more activity in several regions of the brains of BPD patients compared with those of healthy volunteers. These areas included those involved in basic visual processing as well as the amygdala, which governs emotional reactivity and memory, and the superior temporal gyrus, which is involved in the faster, “reflexive” processing of social situations. That pattern of activation suggests that BPD patients may react not only more strongly but also more rapidly to disagreeable images and scenarios, perhaps providing less time to reflect on them rationally or divert attention elsewhere.
In a second study, Koenigsberg’s team asked BPD patients and healthy people to attempt to distance themselves as they viewed another series of emotionally charged pictures. In this case, the researchers saw virtually no activity in regions of BPD patients’ brains, such as the anterior cingulate cortex, that regulate emotion. Regions that help to direct visual attention such as the intraparietal sulcus were also underactive. The study suggests that people with BPD have weaker neurological brakes on their emotional reactions and a hampered ability to distract themselves from emotional triggers.
Moreover, a 2008 study led by neuroscientist Brooks R. King-Casas of Baylor showed that people with BPD lack the brain activity that, in most people, interprets social gestures, such as those that signal trust. The researchers tested the ability of BPD patients to interpret the actions of a partner (in this case, the amount of money he or she invested) in a betting game as signs of trust or its absence—something those with the illness had trouble doing. The scientists found that a brain area called the anterior insula, which responded to the investment level in the healthy participants, was unresponsive to this amount in the BPD patients. The insula ordinarily monitors uncomfortable interactions with others, such as those stemming from the violation of trust and other social norms. But the BPD patients seem to lack this gauge in their brain, leading to their difficulty perceiving a breakdown of trust from others’ actions. As a result, patients may not feel they can trust others [see “Perturbed Personalities,” by Andreas Meyer-Lindenberg; Scientific American Mind, April/May/June 2009]. Thus, although people with BPD may be hypersensitive to subtle facial expressions, they are impaired when it comes to perceiving true signs of social collaboration—or the lack of it. That is, people with BPD may be sensitive to less reliable social cues.
Exercising Restraint
These findings and similar ones have built a case for therapies that make patients aware that they see the world through an emotional microscope and that widen and temper their perspective on life. Although several different psychotherapeutic techniques can help patients tame their emotional reactions to social cues, one of the most widely used— and most successful in treating acute symptoms of BPD—is dialectical behavior therapy (DBT). Developed by psychologist Marsha M. Linehan of the University of Washington, DBT is an innovative form of cognitive-behavior therapy (CBT) designed specifically to treat BPD. It incorporates the central tenets of CBT, in which counselors teach patients to detect and combat distorted thought patterns (the cognitive part) and to counteract problematic behaviors and associated emotions. In addition, DBT incorporates elements of Buddhist meditative practice to help patients maintain a sense of calm.
Therapists first coax patients to acknowledge that they have a problem controlling their emotions. Then they suggest ways of preventing these feelings from becoming overwhelming and triggering inappropriate or impulsive actions. One core strategy is mindfulness, which is the capacity to live in the moment without passing judgment. Therapists teach patients to focus on the physical environment they currently inhabit—say, the colors in the room, the trickling of a brook or even their own breathing—to move their mind away from their tumultuous inner thoughts.
Another key component of dialectical behavioral therapy is the use of self-soothing techniques to manage mood swings. These methods include practicing deep breathing, taking walks, listening to music and having a nice meal. Therapists also instruct
patients about how to build healthy relationships by telling them, for example, to resist the urge to attach themselves too quickly to someone: BPD patients have a reputation for coupling up with each other at an alarming rate, falling in love, say, after just a few group therapy sessions—and then enduring stormy breakups of these impulsive pairings. Other relationship skills BPD patients need are learning to appreciate another person’s point of view and to adopt a friendly manner when dealing with others.
To counteract their tendency to overreact to their emotions, patients practice doing the exact opposite of what they are inclined to do. If, for example, they feel intense anger and the urge to blow up at someone, they might instead remove themselves from the situation. Or if they are so depressed they want to stay in bed all day, they get up and take a walk. Therapists also remind patients to get enough sleep and eat regular meals, both of which can improve emotional control. (Unlike most therapists, DBT practitioners encourage their patients to phone them between sessions, a tactic designed to make vulnerable patients feel validated and supported.)
At least one study suggests that these strategies are effective. In 2006 Linehan and her colleagues showed that DBT halved suicide attempts among 52 BPD patients, compared with nonbehavioral therapies tested on another group of 49 patients. DBT also reduced the use of emergency room and inpatient services by these individuals more than other therapies did.
Still other forms of psychotherapy may help patients as well. In fact, results from the two major long-term studies to date of BPD indicate that regular treatment has a surprisingly positive effect, especially on the most serious symptoms, namely, self-harm and suicidal urges. In one of these investigations, psychiatrist Mary Zanarini of Harvard’s McLean Hospital and her colleagues reported in 2006 that after 10 years of therapy both in and outside the hospital, 88 percent of the 242 patients no longer met the criteria for BPD. In addition, recurrences in these patients were rare, suggesting that patients can learn how to successfully manage their symptoms.
Wang, now age 31 and living on Long Island, N.Y., credits her survival to the three years of DBT she received after her diagnosis. “My turmoil used to be all jumbled into this big ball of despair,” she says. “I’ve learned that emotions run a certain course—and within this course we have choices to make. Now my emotion no longer has the control it once had, and for the most part I can manage it.”
Although Wang still occasionally struggles with thoughts of self-harm and suicide, her improved ability to manage her emotions has stabilized her marriage as well as her relationships with colleagues in her job as a graphic designer and her own sense of herself. “I used to think I was crazy, and feeling crazy is very lonely,” she says. “When I found out I had BPD, everything made sense. I understood that it was a disorder and that I was part of a community of people struggling with it. I was no longer alone.”