BORDERLINE PERSONALITY DISORDER I HATE YOU, PLEASE DON’T LEAVE ME Tori Collins

BPD  Borderline personality disorder (BPD) is a condition in which a person makes impulsive actions, has an unstable mood and chaotic relationships.  BPD affects 1-2% of the general population  Most common in young women  “Borderline” between neurosis and psychosis

DSM-IV  Affective Criteria  Periods of intense anger and difficulty controlling anger  Chronic feelings of emptiness  Affective instability: episodes of dysphoria, irritability, or anxiety lasting from a few hours to a few days  Cognitive Criteria  Transient paranoia/dissociation due to stress  Unstable self image or sense of identity

DSM-IV  Behavioral Criteria  Recurrent suicidal behavior, gestures, threats, or self- mutilation  Impulsivity in at least two areas that are self-damaging that do not include the above (i.e. substance abuse)  Interpersonal Criteria  Frantic efforts to avoid real or imagined abandonment  Unstable and intense relationships alternating between extremes of idealization/devaluation

BPD  Causal factors  Childhood abuse is reported by many patients  Genetic: sparse data 37% concordance rate for monozygotic twins (7% dizygotic) multivariate analysis reveals 47% heritability in “emotional dysregulation”

Lieb, 2004

BPD  Treatments  Group and individual psychotherapy  Antidepressants, mood stabilizers, antipsychotics Regulate 5HT/NE/GABA  Dialectical behavior therapy developed specifically for treatment of BPD Teaches emotional regulation Tolerate distress Be more effective in interpersonal conflict Control attention to “be in the moment”

BPD  BPD is often comorbid with other psychiatric illnesses  Major depression  Eating disorders  Anxiety disorders  Other personality disorders  Post-traumatic stress disorder 46-56% of BPD patients are diagnosed with PTSD

BPD  BPD and PTSD can both be caused by the experience of traumatic events  BPD is considered by some to be a form of complex chronic PTSD  BPD is often associated with childhood trauma  Neglect, abuse  Most frequently associated with sexual abuse  Impulsive behavior puts those with BPD at greater risk for experiencing traumatic events such as driving accidents and physical or sexual assault

REDUCED AMYGDALA AND HIPPOCAMPUS SIZE IN TRAUMA-EXPOSED WOMEN WITH BORDERLINE PERSONALITY DISORDER AND WITHOUT POSTTRAUMATIC STRESS DISORDER Godehard Weniger, MD; Claudia Lange, PhD; Ulrich Sachsse, MD; Eva Irle, PhD

Background  PTSD associated with reduced volume of the hippocampus and left amygdala and with reduced cognitive functions  Small hippocampus and amygdala size are also seen in patients with PTSD and BPD  Current study: are reduced amygdala and hippocampus volume and cognitive deficits present in patients with BPD and without PTSD?

Methods  24 female in-patients exposed to severe physical and sexual childhood abuse  25 matched healthy controls  Assessed for history of neurologic disease, MRI abnormalities, psychotic disorders, bipolar disorders, substance abuse, and dissociative disorders  Diagnoses of BPD without PSTD based on DSM-IV criteria and SCID interviews

Methods  Comorbid disorders in subjects included major depression, alchohol-related disorders and eating disorders  Patients had been medicated for at least 3 weeks prior to the study  Some were given antidepressants and/or sedatives

Methods  Measured intracranial and total brain volume by MRI, separating the amygdala and hippocampus  Measured intellectual, mnemonic and attentional function using the WAIS-R, WMS-R, Trail Making Test (TMT), and the subtest TAP.

Results  Groups:  10 patients met criteria for PTSD  14 met only 1 DSM-IV criterion for PTSD (5 are required)

Results  No difference between groups in neglect, physical abuse, disorder duration, depression severity, global psychological distress and alcohol consumption  Patients without PTSD reported more sexual abuse and intrusion of traumatic material

Results  Patients with PTSD had significantly smaller total brain volumes and increased global atrophy (brain:skull ratio) when compared with controls  3 × 2 (group × hemisphere) ANCOVA comparing the amygdala volumes of patients with and without PTSD and controls indicated smaller amygdala volumes of trauma exposed patients  Patients with and without PTSD did not differ significantly

Results  The overall 3 × 2 (group × hemisphere) ANCOVA comparing the hippocampus volumes of patients with and without PTSD indicated smaller hippocampus volumes of trauma-exposed patients  post-hoc 2 × 2 (group × hemisphere) ANCOVA for each trauma-exposed group and the control group confirmed the results in both regions

Results  During ANCOVA testing of amygdala and hippocampus volumes while introducing IQ as a covariate, the results of all analyses remained the same  except comparison of hippocampus volumes across the group with PTSD and controls, which did not yield a significant effect of group

Results  Neuropsychological  patients with PTSD were significantly impaired on all intellectual and mnemonic measures except verbal memory and delayed recall  patients without PTSD were unimpaired  patients with PTSD had lower test scores

Results  Stats  Performance IQ (R 2 = 0.261, p = 0.011), attention/concentration (WMS-R; R 2 = 0.319, p = 0.004) and part B of the TMT (R 2 = 0.217, p = 0.022) were significantly predicted by right hippocampus volume  Larger hippocamus volume = better test performance

Discussion  Overall  12% hippocampus size reduction in patients with BPD and PTSD  11% reduction in those without PTSD  34% amygdala size reduction in patients with BPD and PTSD  22% reduction in those without PTSD

Discussion  BPD, irrespective of traumatic exposure orsubsequent development of PTSD, has a negative impact on amygdala and hippocampus size.  Studies of BPD without trauma exposure are needed

Discussion  Cognitive deficits have been repeatedly reported for patients with PTSD  better cognitive performance in patients without PTSD; statistical significance?  Total brain volumes of patients with PTSD were decreased, global atrophy increased  Head trauma?