Transcript From Brain to mind… - Bernadette Grosjean.MD

Borderline Personality Disorder:
From Brain to Mind…
B.Grosjean.MD.
Harbor UCLA.Grand Round
2-7-2006.
Psychotherapy
NMDA
Glutamate
Pharmacotherapy
Attachment Theory
PCP 5HT
PTSD
Education
Neuroimaging
Learning theory
Psychoanalysis
Dissociation
Theory of mind
Emotion
Psychopathology
Molecular biology
Genetic
Cognition
Borderline Personality Disorder
Brain
Mind
Borderline Personality Disorder
Epidemiology
 Prevalence:
• 1-2% general population (USA).
• 71-73 % women
 Up to 10% of psychiatric outpatients and 20% of
inpatients.
Borderline Personality Disorder
Etiopathology
Genetic Disposition/
Temperament
Pathology of early attachment:
• neglect
• trauma
• chaotic-disorganized?
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HPA axis hypersensitivity
Neurotransmitter Systems ?
?? NMDA receptors dysfunction??
??? Mirror neurons dysfunction???
Inpatient BPD: 76 % reported physical abuse; 86%
reported sexual abuse (26% w/o BPD)
Borderline Personality Disorder
Diagnosis
Behavioral/ affect regulation/
Cognition
Perceptual Alteration
Borderline Personality Disorder
1- Behavioral Symptoms
Poor affect regulation
Poor impulse control
Unstable relationships
Risky behaviors (substance
abuse etc…)
Suicidality, self harm
Borderline Personality Disorder
2- Cognition
Problems with:
 Working memory
 Autobiographical memory
 Learning processes (reversal learning?)
 Mentalization.
 Executive functioning
 Tasks that require controlled attention
processing
 Attentional network involved in conflict
resolution and in the voluntary inhibition of
thought and behavior.
Fonagy,Bateman 1995,2004
Posner 2002,Lezenweger 2004;Fertuck 2005.
Borderline Personality Disorder
3- Perceptual alterations
 Impaired emotion recognition as revealed by
the impaired ability to read and/or to interpret
facial expressions of emotion Donegan 2003.
 Dissociation Zanarini et al 2001.
Borderline Personality Disorder
Neuroimaging
 Reduced hippocampal and amygdalar volumes.
Driessen 2000;Rush 2003; Terbatz van Elst 2003.
 Aberrant functioning in the cingulate cortex.
Hazlett 2005 Milham et al 2005.
 FMRI of BPD patients listening to scripts
describing abandonment events show dysfunction
of medial and dorso-prefrontal cortex. Schmal 2003.
 Smaller corpus callosum in abused and or
neglected children. Teicher 2003,2004
Treatment ?
Borderline Personality Disorder
Validated/Manualized Treatments
Transference Focused Psychotherapy (TFP)
Otto Kernberg. Object relation theory. 1967.
Dialectic Behavioral Therapy (DBT)
Marsha Linehan Deficit in self regulation.1994.
Mentalization Based Treatment (MBT).
Bateman, Fonagy. Deficit in mentalization processes. 2000.
Medications can be an adjunction but are useless
without psychotherapy.
75% meet criteria for remission after 6 years
60-75% after 20 y F/u no longer meet criteria for BPD
9% completed suicide
BRAIN
• 100 billion neurons
• Each develops between 1,000 to 10,000
connections with other neurons
Geography of the brain
Right
Right hemisphere
(develop before left):
 Holistic
 non verbal, music
 visual
 Face recognition
 ambiguity
 empathy
 autobiographical memory
integrated map of the
body
and
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Left
Left Hemisphere:
Linear processing
Linguistic
Logical-syllogistic reasoning
Literal
brings cohesion (not
coherence) to “make sense”
(integration) needs
communication with Right
Hemisphere/corpus callosum.
Corpus Callosum
“INTEGRATION”
• largest white
matter structure
in the
mammalian
brain
• connects the
left and right
cerebral
hemispheres.
Hippocampus
“PUZZLE ASSEMBLER”.
• Essential role in the formation of
new memories (episodic or
autobiographical/ EXPLICIT)
• required for simple spatial
memory tasks .
Amygdala
“EMOTIONAL BRAIN”
• Key role in the emotions (fear
pleasure).
• Key role in implicit, emotional
memories: interprets the
emotional significance of the
experience.
Memory
IMPLICIT
• Present at birth
• No sense of recollection
present when memories
recalled and encoded
• Includes behavioral,
emotional, perceptual, and
possibly bodily memory
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EXPLICIT
> 2 y/o
Requires conscious attention
Sense of recollection present
when being recalled
Includes semantic (factual)
and episodic
(autobiographical) memory
Involves the hippocampus
Anterior Cingulate Cortex
“Conflict monitoring”
• Vital to cognitive functions,
such as reward anticipation,
decision-making, empathy,
and emotion.
• Involved in a variety of
autonomic functions (HR, BP)
• responsible for rendering
new memories permanent.
Pre-frontal cortex
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Body regulation
Emotional regulation
Attunement
Response Flexibility
Empathy
Fear Extinction
Intuition
Morality
Self-Knowing Awareness
Medial Prefrontal Cortex
 Activated by observation of
social interaction
 Activated during mentalization
 Activated with meditation, body
exercises, prayer
 Size correlate with degree of
meditation ?
NEUROPLASTICITY
NEUROPLASTICITY
Development shapes the brain by altering the strength
of synaptic connections within the brain.
 synapses can be strengthened, weakened or
eliminated (pruning)
 new synapses can be formed in response to
experience
 genetic information, toxic substance, and stressful or
absent experience can lead to elimination of
synapses.
Brain growth spurt in humans between the last
3 months of pregnancy and extends into the
first 3 years of life.
Major Pruning end around the end of puberty.
Adult brain remains plastic during the entire
life.
Neurotransmission
• Serotonin: impulsive aggression, working memory and
inhibitory processes
• Dopamine: emotional regulation, motivational systems,
and cognitive perceptual phenomenon.
Glutamate
• Primary excitatory neurotransmitter in the
mammalian brain.
• Involved in many CNS mechanisms of plasticity
including those contributing to learning and
memory.
N-methyl-D-aspartate subtype
glutamate receptors (NMDARs)
• Concentrated in the hippocampus, forebrain,
amygdala, caudate, putamen and thalamus
(rodents)
• NMDAR, can “detect” the coincidence of 2
events, so called “associativity”.
NMDA Receptors
NMDARs
• Hypofunctioning of the NMDAR, causes learning
impairment, memory impairment (working memory)
and dissociation.
• Overactivation of NMDA receptor via the glutamate
site results in neurotoxicity and cell death.
Mirror
Neurons
The Miracle ?
Mirror
Neurons
A class of neurons that discharge not only
when a monkey executes goal-related hand
action, but also when observing other
individuals executing similar actions.
Gallese, Rizzolatti et al. 1996
Mirror
Empathy
Neurons
“Einfühlung”
• Iacoboni proposes that the human mirror neuron system,
in concert with the limbic system, play a major role in the
process of understanding the emotion and intention of
other people…and would be at the origin of empathy.
• To empathize, we need to invoke the representation of
the actions associated with the emotions we are
witnessing.
Mirror
Empathy
Neurons
“Einfühlung”
• fMRI study showed that same brain region are
activated while observing an emotion or during the
imitation of the emotional face expression
• These data suggest that we understand the
feelings of others via a mechanism of action
representation, so we build our empathic
resonance in the experience of our acting body and
the emotions associated with specific movements .
“Neural mechanisms of empathy in human: a relay from neural systems for
imitation in limbic area” Carr, Iacoboni et al 2003
MIND 1
The mind develops as the genetically
programmed maturation of the brain
responding to ongoing experiences.
D.Siegel. “The Developing Mind” 1999.
MIND 2
Development is about the creation of
specific circuits, not merely the overall
amount of synapses in the brain.
The ways in which the circuits regulating
emotional and social functioning develop is
profoundly influenced by interpersonal
experience beginning early in life.
MIND 3
Attachment researches indicate that
“good attachment relationship are likely to
promote the development of integrative
capacities of the brain in enabling the
acquisition of emotional, cognitive and
interpersonal abilities”.
MIND
Siegel (2001) propose as the qualities that
foster secure attachment:
 Collaboration
 Reflective dialogue
 Repair
 Coherent narratives
 Emotional communication
BETWEEN BRAIN AND MIND
Emotion
Mentalization
Emotions
“Facial expression are a crucial component of
human emotional and social behavior and are
believed to represent innate and automatic
behavior patterns”
Darwin 1872
Emotions
 Emotional expression allow the rapid communication of
information between individual.
 They can be viewed as reinforcers that modulate a particular
behavior.
Mentalization
Mentalization
• Ability to read the expression on another’s
face and know what this person is feeling.
• Ability to represent the mental states of
others, i.e. their thoughts, desires, beliefs,
intention and knowledge.
What prevent acquisition of mentalization ?
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Genetic?
Toxic environment ?
Trauma
Neglect
Chaos
The Challenge
• 906,000 children victims of abuse or neglect in
2003. (1.24% of general population).
• Neglect: 60 %; physical abuse19%; sexual
abuse 10 % ; emotional abuse 5 % : "other“
17%.
• Children ages birth to 3 years had the highest
rates of victimization at 1.6% of the same age
group. Girls were slightly more likely to be
victims than boys.
Child Maltreatment 2003: Summary of Key Findings
National Clearinghouse on Child Abuse and Neglect Information 2005
Bruised brains aching minds
Developmental Effects of Child Abuse and Neglect
• High levels of cortisol destroy synapses.
• Abuse, neglect and chronic states of misattunement
lead to an overpruning of synapses (R OFC) leaving
individuals with impaired ability to modulate and
regulate emotion in response to stress.
Bruised brains aching minds
Developmental Effects of Child Abuse and Neglect
• Overwhelmed hippocampus is unable to process
explicit memory
• Implicit recollection w/o explicit processing maybe the
source of flashback.
Maltreated children have multiple problems:
– Isolation, hence fewer non parental model of
emotional communication.
– Difficulties in recognition, expression and
understanding of emotions (Camras et al 1996).
– partial and temporary collapse of mentalization
(Allen 2001).
• Neglected children have difficulties to discriminate
between angry, sad and fearful expression
• Physically abused children have difficulties recognizing
sadness and disgust but not anger.
• Both have trend to perform better than control children in
detecting masked expressions of emotions and a bias
(increased accuracy) toward detection of threat related
information such as anger.
Recognizing emotion in faces: Developmental Effects of child abuse and neglect”.
Pollak, et al.2000.
Treatments ?
Basics !!!!
Genetic
Prenatal
Early life
Childhood
Teenager
Adulthood
Prevention/education/social support
Prevention/education/social support
Prevention/education/social support
Prevention/education/social support
Prevention/education/social support
Prevention/education/social support
Importance of early intervention.
• Effectiveness of home visiting (6.5 during pregnancy)
by nurses.
• Outcome: at 6 months of age, nurses-visited infants
born to women with low psychological resources, in
contrast to their control group had:
– less emotional vulnerability
– higher emotional vitality
– At 21 month they were less language delays.
Home Visiting by Paraprofessionals and by Nurses: a
Randomized, controlled Trial. Olds et al; Pediatrics 2002.
From Brain…
“When neurons fire together , they wire
together” (Donald Hebb).
Experiences turn on the genetic machinery and
through the synthesis of new proteins, change
and/or create internal connections in the brain.
…to Mind
In therapy: new learning is verbal (symbolic) and
non verbal (emotional).
While treating patients with a very poor quality of
attachment history (difficulties at emotional and
mentalization level), it is crucial to pay great
attention to the “attachment quality” of the
therapeutic relationship (collaboration; repair;
coherent narratives; emotional communication)
Traditional psychotherapy have focused on
changes related to the interplay between
emotions and thoughts.
Most therapies have essentially ignored
changes related to bodily states.
Neurobiology indicate how a global approach
(including physical well being) of the person is
essential for improving general condition.
BPD from Brain to Mind…


 Genetic

vulnerability
 Neurobiological 
vulnerability

 Chaos

 Neglect

 Abuse

 Chronic stress


Emotion dysregulation
Dissociation
Identity diffusion
Emotion expression
Cognitive dysfunctions
Mentalization deficit
Learning problems
Memory problems
HPA hypereactivity
Slow return to baseline
 Comorbid: depression,
substance abuse
dependence
 Stable attachment;
lower level of stress
 Education; skills
training
 Integration of body
well being
 Diversification of
emotion expression,
learning cues
 Reactivation of old
patterns and recreation of
autobiographic
narrative that make
sense and authorize
integration
 Increase self
awareness and
symbolization
capacity
• PROVIDE STRUCTURE.
• RELIABLE AND CONSISTENT:
– Doing what you have agreed to do
– Avoid expression of extreme emotions
– Inquisitive and curious rather than aloof and
single minded
– Simple rather than clever.
• ABLE TO DECREASE AROUSAL (calm
under fire, be matter of fact).
• HELP PATIENTS TO VALIDATE THEIR
OWN EXPERIENCES.
• ACCEPT THAT YOU MAKE MISTAKE AND
RECOGNIZE ENACTMENT.
“Emotion ceases to be suffering as soon as we
form a clear and precise picture of it”. Spinoza.
“A fragile ego left alone remains fragile. Medication or
superficial support alone is not a substitute for the
feeling that one is understood by another human being”.
Picture by Gregory Colbert
Thank you!
www.bgrosjean.com
Picture by Gregory Colbert