Some are suggesting that this study is some sort of groundbreaking work in understanding borderline personality disorder. While an interesting brain study, I’d suggest it tells us a lot less than the authors purport.
First, this is a classic laboratory study. And while laboratory studies of this nature are the foundation for later clinically-relevant studies, they are, by their very nature, limited in what they can test and how they test it. With limited testing ability (and re-test ability, accounting for different moods on different days, which this study did not do), results are not generalizable to a clinical population — e.g., people with this actual disorder.
Why is this a laboratory test? Because borderline personality disorder is first and foremost characterized by emotional lability, especially in interpersonal relationships. So would a word test with a computer be the best way to test such symptoms? Umm, I would humbly suggest, “No.”
Behavioral response was based on orthographically based cues: participants were instructed to perform a right-index-finger button-press immediately after (silently) reading a word appearing in normal font (go trial) and to inhibit this response after reading a word in italicized font (no-go trial). Button-press responses and reaction times were recorded. A total of 192 distinct linguistic stimuli were used (64 negative, 64 positive, 64 neutral). Words were balanced across all valence conditions for frequency, word length, part of speech, and imageability.
As far as I can figure, that’s not a test based upon any kind of real-world stimuli or interactions. It’s a behavioral word test. And while some of the words may have been designed to elicit an emotional response, a single word really can’t be seriously used as a stand-in for one’s emotional response to a situation with someone you care about.
Sample size? Paltry: 16 patients with borderline personality disorder and 14 “normal” people who had no borderline diagnosis. 11 of the 16 were on medications at the time of the trial, suggesting they should already be receiving some sort of therapeutic benefits from the medications (and therefore the researchers results may be hopelessly confounded; alternatively, the medications they were receiving had no effect on their borderline personality disorder — neither hypothesis strikes me as boding particularly well).
But the study is a good one for what it shows: while performing a simple cognitive task, people with borderline personality disorder had less activation of the subgenual anterior cingulate cortex (a specific area of the brain which is theorized to help modulate our emotions). Surprise, surprise — the brain area thought to regulate emotions shows “less activation” in someone who has problems regulating his or her emotions.
The real challenge in terms of overstating this study’s results comes with the accompanying editorial by Siegle, which is just glowing in its admiration for the study. It also nicely illustrates what’s wrong with a peer-review process that publishes self-congratulatory editorials, too.
These future directions notwithstanding, with the data from just this study, we can begin to infer that when individuals with borderline personality disorder display decreased impulse control, this loss of impulse control may reflect a deficit in recruitment of brain mechanisms of emotion regulation, and this process may be potentiated by context. Particularly stressful or negative contexts could lead to more impaired impulse control.
An implication for psychotherapy process might be that it is important to address contextual factors when considering impulse control in borderline personality disorder.
Anybody who has spent any significant amount of time helping to treat people with borderline personality disorder already knows that context and stress are important factors when it comes to understanding emotional lability. Nobody needed an fMRI study to confirm this fact. In fact, we have very successful treatment paradigms and therapies for borderline personality disorder, fMRIs notwithstanding (e.g., DBT, which has a significant research base). Heck, any first-year student in psychology knows that “context” and “stress” are likely to lead to greater flare-ups of a person’s disorder, whether it be borderline, depression or bipolar disorder.
But this is the closing zinger in the editorial that we enjoyed most:
In the past, basic neuroimaging findings have often remained separate from clinical practice. But with designs such as that used by Silbersweig et al., which so closely reflects the observed clinical phenomena, and results that appear so closely aligned with clinical studies, it is increasingly easy to recommend that clinicians read this study carefully and begin to apply its lessons, ideally to better design and monitor cognitive and pharmacological treatments by addressing the underlying neurobiology of borderline personality disorder.
Well, let’s see (trying my best to ignore the tortuous grammar)… This design had virtually nothing to do with someone who experiences this disorder’s reality (button pressing in response to a computer word versus emotional lability in relationships). We already have a well-established psychotherapy that has significant and strong research to prove its effectiveness for borderline personality disorder (DBT). We have no FDA-approved medications for borderline. You’ve got to wonder which direction he was suggesting we go there, no?
Perhaps we would do well to first really understand the “underlying neurobiology” of the brain itself before we start tackling the disorders associated with it, too, while we’re at it.
References:
Silbersweig, D. et. al . (2007). Failure of Frontolimbic Inhibitory Function in the Context of Negative Emotion in Borderline Personality Disorder. Am J Psychiatry 164:1832-1841.
Siegle, G.J. (2007). Brain Mechanisms of Borderline Personality Disorder at the Intersection of Cognition, Emotion, and the Clinic. Am J Psychiatry 164:1776-1779.
9 comments
I have borderline. Thanks for this post.
I am wondering of Dr. Grohol has heard of the scientific concept of “converging evidence?” There are different places in the brain involved with emotional regulation. As we understand more about how the brain responds to different stimuli under real and simulated conditions, we learn more about the brain and perhaps the disorder. Certainly there are caveats to show this study is preliminary. But many studies using fMTI have small sample sizes. Also, tasks of simple stimuli presentation have shown to be illuminating. Peraps Dr. Grohol would like to review his neuropsychology info to realize that there is more to this study and that perhaps he is being overly critical.
Converging evidence is fantastic. But please tell me how learning that the brain area thought to regulate emotions shows “less activation” in someone who has problems regulating his or her emotions is helpful to researchers or clinicians — I’m all ears.
Hello Dr Grohol,
I think the point is that they found EVIDENCE, proof, you know. Not just lengthy theoretical explorations like psychology has been famous for to explain disorders like schizophrenia. The reaction from the psychoanalytic community at the time was probably as flippant in tone as this article is.
Even with a small sample, it’s better than broad, loosely defined retrospective meta-analyses carried out mostly since DSM III, on the effectiveness (or rather, ineffectiveness as most patients drop out) of various psychotherapy modes for BPD over time.
As one therapist might say to another, try to be open to new possibilities and hope for more immediate treatment for these severely disordered patients, rather than cling to old models that clearly take too long as 5 to 10% afflicted are continuing to commit suicide, in spite of advances in talk therapy.
Wishing you the best.
I made my argument in the article — a word test isn’t equivalent to measuring actual, real behavior in a real-world environment.
Functional MRI studies are notorious in science because we’re taken in by the enticing images of brain activity. A study such as this one may help us better understand a component of borderline personality disorder — but it literally shed no new light on the problem.
This study showed that stress or negative situations perhaps could possibly lead to increased symptoms of the disorder. This is not news to any researcher or clinician (or, I dare say, most people with the disorder).
If you’d like, a more positive spin on this study’s findings would be to say, “This study confirmed previous findings that stress or negative situations can exacerbate symptoms of this disorder.”
This is fascinating to me though.
Because personally, dx BPD, I spent years feeling absolutely nothing. I floated. I sometimes tried to express how unreal reality was, but no one understood me. There were occasional horrendously painful breakthroughs of overwhelming negative emotions like fear, self-loathing, total despair… but except for a constant nebulous underlying tension, it was always all or nothing and almost always nothing. Mostly I never bothered anyone, I never saw a doctor, I did not compete with anyone, I painstakingly avoided “waking” anyone’s jealousy or envy, I never invested myself emotionally in my relationships; it was as if I had never been born.
My ability to “shut down” has well served me in moments of crisis – as the first to arrive on the scene of a fatal car accident and attend to those gravely hurt, horribly mutilated but still breathing, still conscious, would be one example. Or in caring for a relative up until her last breath so that she could die of cancer in her own home.
If the dx of BPD was accurate in my case, I am firmly convinced that what is not talked about enough in BPD is vaguely referred to as “dissociation” or “depersonalization”. I think it is not limited to, but includes -most importantly- a numbing of the senses, a shutdown of any normal range of neutral or positive emotions or more modulated, lighter negative ones.
I think many of those of us with BPD are actually invisible most of the time and then suddenly too visible when emotionally overwhelmed. So much of the description for BPD is only true in times of crisis; I remember in one of my worst crises, which dragged on for years, how I desperately longed for any animate being – even a cat – to be by my side, which was totally out of sync with how content I am normally to work by myself, to spend hours reading, to travel alone, as I am rather introverted by nature.
I find it ironic that BPD sufferer’s are seen as so emotional, when the bottom line is that we actually have a much more limited range of emotions that your average person. Perhaps because anxiety arises so often so quickly to throttle any more nuanced emotional reaction…
It’s true that I am particularly introspective by nature and internalize everything so perhaps my experience as BPD’ed is far from typical. But still I’m convinced that there is something in this study that merits close attention.
You describe me perfectly well Zephyr, in my early life. Imagine being this way and on the rare occassion you come under mental health care, get a Borderline PD only to be treated like the despised attention seeking, pain in the ass borderline you are not. I kept to myself and avoided any kind of treatment for just this reason. I saw the attitudes and was shamed and avoided that kind of help which would of been more damaging to me than helpful. Luckily some attitudes have changed as more is learnt and I have now an enlightend therapist. I have grown alot in strenght emotionaly to withstand those strong emotions, though still have setbacks sometimes. Just so many wasted early years before.
I am sixteen years of age and I read a lot of places that psychologists aren’t suppose to diagnose a person under the age of 18 because of the still developing personality. I was diagnosed in December of last year and this constantly interfears with my life because I don’t have very good coping skills and I “like” to dwell on things for a long time. I think if I wouldn’t have been diagnose and told about it I wouldn’t dwell on it so much…
My name is dayna and I’m 17 years old. I was told by my psychologist and the crisis team at the hospital recently that I have borderline personality disorder. I told my dad which allowed him to finally admiy the fact that he has had his whole life. My aunty had it too. She killed herself a couple years back.. I can’t let go of the fact that my dad knew and never told me. I have abused drugs and alcohol for most of my teen years from just not knowing what the hell is wrong with me and just wanting the feeling to go away! I feel that had made it a lot worse for me.. When I first found out I was so relieved. I was OK for the first day… but then I started realising what this meant… years of more pain and more therapy.. but I know i will never get anywhere dwelling on it. I need to focus on myself and not hurting others around me, cuz that’s really what gets me down. Raina, now that you know the problem think of it as a positive. You are now able to get the help you need to be happy. Be thankful we are so young and have a chance to have a normal life when we are older. Be proud of who you are, who really is “normal” these days anyway. I like to think of positive things about myself and others everyday. Also things I’m greatful for. Sounds stupid I know but after a while it makes you start appreciating the little things cuz at first I was writing little things like I’m greatful I could eat today. And now there a