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Borderline Personality Disorder: Toward Integration

Published online by Cambridge University Press:  07 November 2014

Dan J. Stein
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Abstract

Several psychiatric disorders, including borderline personality disorder (BPD), are characterized by emotional dysregulation and impulse dyscontrol. More specifically, symptoms in patients with BPD often occur within the context of disruptions in attachment and related distortions in cognitive-affective processing of the self and others. From a neurocircuitry perspective, findings include prefrontal hypoactivity, amygdala hyperreactivity, and alterations in prefrontal-limbic interaction. Molecular pathways relevant to these circuits include the serotonergic, noradrenergic, and dopaminergic systems, and there is some evidence that pharmacotherapy with agents that act on these systems may be useful. Given the disruptions in attachment and schemas of the self and others in BPD, establishing a therapeutic alliance is crucial while psychotherapy remains the cornerstone of an integrated approach to management.

Type
Pearls in Clinical Neuroscience
Information
CNS Spectrums , Volume 14 , Issue 7 , July 2009 , pp. 352 - 356
Copyright
Copyright © Cambridge University Press 2009

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References

REFERENCES

1.Gunderson, JG. Borderline personality disorder: ontogeny of a diagnosis. Am J Psychiatry. 2009;166:530–539.Google Scholar
2.Siever, LJ, Davis, KL. A psychobiological perspective on the personality disorders. Am J Psychiatry. 1991;148:1647–1658.Google Scholar
3.Melges, FT, Swartz, MS. Oscillations of attachment in borderline personality disorder. Am J Psychiatry. 1989;146:1115–1120.Google Scholar
4.Levy, KN. The implications of attachment theory and research for understanding borderline personality disorder. Dev Psychopathol. 2005;17:959–986.Google Scholar
5.Giovanni, L, Mauricio, C, Benedetto, F. Attachment theory and multiple integrated treatments of borderline patients. J Am Acad of Psychoanal Dyn Psychiatry. 2008;36:295–315.Google Scholar
6.Gabbard, GO, Horowitz, MJ. Insight, transference interpretation, and therapeutic change in the dynamic psychotherapy of borderline personality disorder. Am J Psychiatry. 2009;166:517–521.Google Scholar
7.Peter, F, Anthony, B. The Development of Borderline Personality Disorder: A Mentalizing Model. J Pers Disord. 2008;22:4–21.Google Scholar
8.Kellogg, SH, Young, JE. Schema therapy for borderline personality disorder. J Clin Psychol. 2006;62:445–458.Google Scholar
9.Stein, DJ, Moeller, FG. The man who turned bad. CNS Spectr 2005;10:88–90.Google Scholar
10.Johnson, PA, Hurley, RA, Benkelfat, C, Herpertz, SC, Taber, KH. Understanding emotion regulation in borderline personality disorder: contributions of neuroimaging. J Neuropsychiatry Clin Neurosci. 2003;15:397–402.Google Scholar
11.Stein, DJ, Horn, N, Ramesar, R, et al.Bipolar Disorder: Emotional Dysregulation and Neuronal Vulnerability. CNS Spectr. 2009;14:122–126.Google Scholar
12.Stein, DJ, Fan, J, Fossella, J, Russell, VA. Inattention and hyperactivity-impulsivity: psychobiological and evolutionary underpinnings of ADHD. CNS Spectr. 2007;12:190–196.Google Scholar
13.Rosenthal, MZ, Gratz, KL, Kosson, DS, et al.Borderline personality disorder and emotional responding: A review of the research literature. Clin Psychol Rev. 2008;28:75–91.Google Scholar
14.Oldham, JM. Borderline Personality Disorder Comes of Age. Am J Psychiatry. 2009;166:509–511Google Scholar
15.Stein, DJ. Empathy: At the heart of the mind. CNS Spectr. 2005;10:780–783.Google Scholar
16.Stein, DJ. How we see others: the psychobiology of schemas and transference. CNS Spectr. 2009;14:10–13.Google Scholar
17.Stein, DJ. What is the self? A psychobiological perspective. CNS Spectr. 2007;12:333–336Google Scholar
18.Berlin, HA, Rolls, ET, Iversen, SD. Borderline personality disorder, impulsivity, and the orbitofrontal cortex. Am J Psychiatry. 2005;162:2360–2373.Google Scholar
19.New, AS, Goodman, M, Triebwasser, J, Siever, LJ. Recent advances in the biological study of personality disorders. Psychiatr Clin North Am. 2008;31:441–461.Google Scholar
20.Schmahl, C, Bremner, JD. Neuroimaging in borderline personality disorder. J Psychiatr Res. 2006;40:419–427.Google Scholar
21.Lis, E, Greenfield, B, Henry, M, Guile, JM, Dougherty, G. Neuroimaging and genetics of borderline personality disorder: a review. J Psychiatr Neurosci. 2007;32:162–173.Google Scholar
22.Goyer, PF, Andreason, PJ, Semple, WE, et al.Positron-emission tomography and personality disorders. Neuropsychopharmacology. 1994;10:21–28.Google Scholar
23.De La Fuente, JM, Goldman, S, Stanus, E, et al.Brain glucose metabolism in borderline personality disorder. J Psychiatr Res. 1997;31:531–541.Google Scholar
24.Lyoo, IK, Han, MH, Cho, DY. A brain MRI study in subjects with borderline personality disorder. J Affect Disord. 1998;50:235–243.Google Scholar
25.Schmahl, CG, Elzinga, BM, Vermetten, E, Sanislow, C, McGlashan, TH, Bremner, JD. Neural correlates of memories of abandonment in women with and without borderline personality disorder. Biol Psychiatry. 2003;54:142–151.Google Scholar
26.Tebartz van Elst, L, Hesslinger, B, Thiel, T, et al.Frontolimbic brain abnormalities in patients with borderline personality disorder: A volumetric magnetic resonance imaging study. Biol Psychiatry. 2003;54:163–171.Google Scholar
27.Vollm, B, Richardson, P, Stirling, , et al.Neurobiological substrates of antisocial and borderline personality disorder: preliminary results of a functional fMRI study. Crim Behav Ment Health. 2004;14:39–54.Google Scholar
28.Minzenberg, MJ, Fan, J, New, AS, Tang, CY, Siever, LJ. Fronto-limbic dysfunction in response to facial emotion in borderline personality disorder: An event-related fMRI study. Psychiatry Res. 2007;155:231–243.Google Scholar
29.Silbersweig, D, Clarkin, JF, Goldstein, M, et al.Failure of Frontolimbic Inhibitory Function in the Context of Negative Emotion in Borderline Personality Disorder. Am J Psychiatry. 2007;164:1832–1841.Google Scholar
30.Wingenfeld, K, Rullkoetter, N, Mensebach, C, et al.Neural correlates of the individual emotional Stroop in borderline personality disorder. Psychoneuroendocrinology 2009;34:571–586.Google Scholar
31.Hazlett, EA, New, AS, Newmark, R, et al.Reduced anterior and posterior cingulate gray matter in borderline personality disorder. Biol Psychiatry. 2005;58:614–623.Google Scholar
32.Donegan, NH, Sanislow, CA, Blumberg, HP, et al.Amygdala hyperreactivity in borderline personality disorder: Implications for emotional dysregulation. Biol Psychiatry. 2003;54:1284–1293.Google Scholar
33.Herpertz, SC, Dietrich, TM, Wenning, B, et al.Evidence of abnormal amygdala functioning in borderline personality disorder: a functional MRI study. Biol Psychiatry. 2001;15:292–298.Google Scholar
34.Schmahl, CG, Vermetten, E, Elzinga, BM, Douglas Bremner, J. Magnetic resonance imaging of hippocampal and amygdala volume in women with childhood abuse and borderline personality disorder. Psychiatry Res. 2003;122:193–198.Google Scholar
35.Driessen, M, Herrmann, J, Stahl, K, et al.Magnetic resonance imaging volumes of the hippocampus and the amygdala in women with borderline personality disorder and early traumatization. Arch Gen Psychiatry. 2000;57:1115–1122.Google Scholar
36.New, AS, Hazlett, EA, Buchsbaum, MS, et al.Amygdala-prefrontal disconnection in borderline personality disorder. Neuropsychopharmacology. 2009;32:1629–1640.Google Scholar
37.Schmahl, C, Bohus, M, Esposito, F, et al.Neural correlates of antinociception in borderline personality disorder. Arch Gen Psychiatry. 2006;63:659–667.Google Scholar
38.Schnell, K, Dietrich, T, Schnitker, R, Daumann, J, Herpertz, SC. Processing of autobiographical memory retrieval cues in borderline personality disorder. J Affect Disord. 2007;97:253–259.Google Scholar
39.King-Casas, B, Sharp, C, Lomax-Bream, L, Lohrenz, T, Fonagy, P, Montague, PR. The rupture and repair of cooperation in borderline personality disorder. Science. 2008;321:806–810.Google Scholar
40.Brambilla, P, Soloff, PH, Sala, M, Nicoletti, MA, Keshavan, MS, Soares, JC. Anatomical MRI study of borderline personality disorder patients. Psychiatry Res. 2004;131:125–133.Google Scholar
41.Zetzsche, T, Preuss, UW, Frodl, T, et al.Hippocampal volume reduction-and history of aggressive behaviour in patients with borderline personality disorder. Psychiatry Res. 2007;154:157–170.Google Scholar
42.Irle, E, Lange, C, Sachsse, U. Reduced size and abnormal asymmetry of parietal cortex in women with borderline personality disorder. Biol Psychiatry. 2005;57:173–182.Google Scholar
43.Rusch, N, Weber, M, Il'yasovc, KA, et al.Inferior frontal white matter microstructure and patterns of psychopathology in women with borderline personality disorder and comorbid attention-deficit hyperactivity disorder. Neuroimage. 2007;35:738–747.Google Scholar
44.Grant, JE, Correia, S, Brennan-Krohn, T, Malloy, PF, Laidlaw, DH, Schulz, SC. Frontal White Matter Integrity in Borderline Personality Disorder With Self-Injurious Behavior. J Neuropsychiatry Clin Neurosci. 2007;19:383–390.Google Scholar
45.van Elst, LT, Ludaescher, P, Thiel, T, et al.Evidence of disturbed amygdala energy metabolism in patients with borderline personality disorder. Neurosci Lett. 2007;417:36–41.Google Scholar
46.Hollander, E, Stein, DJ, DeCaria, CM, et al.Serotonergic sensitivity in borderline personality disorder: preliminary findings. Am J Psychiatry. 1994;151:277–280.Google Scholar
47.Stein, DJ, Hollander, E, DeCaria, CM, et al.m-Chlorophenylpiperazine challenge in borderline personality disorder: relationship of neuroendocrine response, behavioral response, and clinical measures. Biol Psychiatry. 1996;40:508–513.Google Scholar
48.Leyton, M, Okazawa, H, Diksic, M, et al.Brain regional α-[11C]methyl-Ltryptophan trapping in impulsive subjects with borderline personality disorder. Am J Psychiatry. 2001;158:775–782.Google Scholar
49.Soloff, PH, Meltzer, CC, Greer, PJ, Constantine, D, Kelly, TM. A fenfluramine-activated FDGPET study of borderline personality disorder. Biol Psychiatry. 2000;47:540–547.Google Scholar
50.Siever, LJ, Buchsbaum, M, New, A, et al.d,l-fenfluramine response in impulsive personality disorder assessed with [18F]deoxyglucose positron emission tomography. Neuropsychopharmacology. 1999;20:413–423.Google Scholar
51.Frankle, WG, Lombaro, I, New, AS. et al.Brain serotonin transporter distribution in subjects with impulsive aggressivity: a positron emission study with [11C]McN5652. Am J Psychiatry. 2005;162:915–923.Google Scholar
52.Soloff, PH, Price, JC, Meltzer, CC, Fabio, A, Frank, GK, Kaye, WH. 5HT(2A) receptor binding is increased in borderline personality disorder. Biol Psychiatry 2007;62:580–587.Google Scholar
53.New, AS, Hazlett, EA, Buchsbaum, MS. et al.Blunted prefrontal cortical 18fluorodeoxyglucose positron emission tomography response to meta-chlorophenylpiperazine in impulsive aggression. Arch Gen Psychiatry. 2002;59:621–629.Google Scholar
54.Herman, BH. A possible role of proopiomelanocortin peptides in self-injurious behavior. Prog Neuropsychopharmacol Biol Psychiatry. 1990;14:S109–S139.Google Scholar
55.Stein, DJ, van Honk, J, Ipser, J, et al.Opioids: from physical pain to the pain of social isolation. CNS Spectr. 2007;12:669–670, 672–674.Google Scholar
56.Stein, DJ, Vythilingum, B. Love and attachment: the psychobiology of social bonding. CNS Spectr. 2009;14:239–242.Google Scholar
57.Bailey, JM, Shriver, A. Does childhood sexual abuse cause borderline personality disorder? J Sex Marital Ther. 1999;25:45–47.Google Scholar
58.Stein, DJ. Emotional regulation: Implications for the psychobiology of psychotherapy. CNS Spectr. 2008;13:195–198.Google Scholar
59.Siever, LJ, Torgersen, S, Gunderson, JG, Livesley, WJ, Kendler, KS. The borderline diagnosis III: Identifying endophenotypes for genetic studies. Biol Psychiatry. 2002;51:964–968.Google Scholar
60.Gillath, O, Shaver, PR, Baek, JM, Chun, DS. Genetic correlates of adult attachment style. Pers Soc Psychol Bull. 2008;34:1396–1405.Google Scholar
61.Gunderson, JG, Lyons-Ruth, K. BPD's Interpersonal Hypersensitivity Phenotype: A Gene-Environment-Developmental Model. J Pers Disord. 2008;22:22–41.Google Scholar
62.Jacob, CPMüller, J, Schmidt, M, et al.Cluster B personality disorders are associated with allelic variation of monoamine oxidase A activity. Neuropsychopharmacology. 2005;30:1711–1718.Google Scholar
63.Huang, YY, Cate, SP, Battistuzzi, C, Oquendo, MA, Brent, D, Mann, JJ. An association between a functional polymorphism in the monoamine oxidase a gene promoter, impulsive traits and early abuse experiences. Neuropsychopharmacology. 2004;29:1498–1505.Google Scholar
64.Ni, X, Chan, K, Bulgin, N, et al.Association between serotonin transporter gene and borderline personality disorder. J Psychiatr Res. 2006;40:448–453.Google Scholar
65.Meyer-Lindenberg, A, Buckholtz, JW, Kolachana, B, et al.Neural mechanisms of genetic risk for impulsivity and violence in humans. Proc Natl Acad Sci U S A. 2006;103:6269–6274.Google Scholar
66.Zetzsche, T, Preuss, UW, Bondy, B, et al.5-HT1A receptor gene C 21019 G polymorphism and amygdala volume in borderline personality disorder. Genes Brain Behav. 2008;7:306–313.Google Scholar
67.Buss, DM. Evolutionary personality psychology. Annu Rev Psychol. 1991;45:459–491.Google Scholar
68.Chisholm, J. The evolutionary ecology of attachment organization. Hum Nat. 1996;7:1–37.Google Scholar
69.Molina, JD, López-Muñoz, F, Alamo, C, et al.Borderline personality disorder: A review and reformulation from evolutionary theory. Med Hypotheses. 2009. (epub ahead of print)Google Scholar
70.Ruocco, AM. Reevaluating the Distinction Between Axis I and Axis II Disorders: The Case of Borderline Personality Disorder. J Clin Psychol. 2005;61:1509–1523.Google Scholar
71.Maunder, RG, Hunter, JJ. Assessing patterns of adult attachment in medical patients. Gen Hosp Psychiatry. 2009;31:123–130.Google Scholar
72.Choi-Kain, LW, Gunderson, JG. Mentalization: Ontogeny, Assessment, and Application in the Treatment of Borderline Personality Disorder. Am J Psychiatry. 2008;165:1127–1135.Google Scholar
73.Giesen-Bloo, J, van Dyck, R, Spinhoven, P, et al.Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transferencefocused psychotherapy. Arch Gen Psychiatry. 2006;63:649–658.Google Scholar
74.van Asselt, ADI, Dirksen, CD, Arntz, A, et al.Out-patient psychotherapy for borderline personality disorder: cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy. Br J Psychiatry. 2008;192:450–457.Google Scholar
75.Linehan, MMCognitive-Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford Press; 1993.Google Scholar
76.Blum, N, St.John, D, Pfohl, B, et al.Systems Training for Emotional Predictability and Problem Solving (STEPPS) for Outpatients With Borderline Personality Disorder: A Randomized Controlled Trial and 1-Year Follow-Up. Am J Psychiatry. 2008;165:468–478.Google Scholar
77.Zanarini, M C. Update on pharmacotherapy of borderline personality disorder. Curr Psychiatry Rep. 2004;6:66–70.Google Scholar
78.Hollander, E, Allen, A, Lopez, RP, et al.A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry. 2001;62:199–203.Google Scholar
79.Paris, J, Zweig-Frank, H. A 27-year follow-up of patients with borderline personality disorder. Compr Psychiatry. 2001;42:482–487.Google Scholar
80.New, AS, Buchsbaum, MS, Hazlett, EA, et al.Fluoxetine increases relative metabolic rate in prefrontal cortex in impulsive aggression. Psychopharmacology (Bert). 2004;176:451–458.Google Scholar
81.Schnell, K, Herpertz, SC. Effects of dialectic-behavioral-therapy on the neural correlates of affective hyperarousal in borderline personality disorder. J Psychiatr Res. 2007;41:837–847.Google Scholar
82.MacKinnon, DF, Pies, R. Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders. Bipolar Disord. 2006;8:1–14.Google Scholar
83.Sripada, CS, Silk, KR. The Role of Functional Neuroimaging in Exploring the Overlap Between Borderline Personality Disorder and Bipolar Disorder. Curr Psychiatry Rep. 2007;9:40–45.Google Scholar
84.van der Kolk, B, Pelcovitz, D, Roth, S, Mandel, F, McFarlane, A, Herman, JL. Dissociation, somatization, and affect dysregulation: The complexity of adaptation to trauma. Am J Psychiatry. 1996;153(Suppl 7):83–93.Google Scholar
85.Schmahl, CG, Vermetten, E, Elzinga, BM, et al.A positron emission tomography study of memories of childhood abuse in borderline personality disorder. Biol Psychiatry. 2004;55:759–765.Google Scholar
86.Driessen, M, Beblo, T, Mertens, M, et al.Posttraumatic stress disorder and fMRI activation patterns of traumatic memory in patients with borderline personality disorder. Biol Psychiatry. 2004;55:603–611.Google Scholar