Heightened Emotional Sensitivity and Transference in BPD

1
Heightened Emotional Sensitivity and Transference
in BPD

• Glen O. Gabbard, M.D.Brown Foundation Chair of
  PsychoanalysisProfessor of Psychiatry Baylor
  College of Medicine
• Training Supervising Analyst
  Houston-Galveston Psychoanalytic
  Institute

2
The Role of the Amygdala

• The amygdala increases vigilance
• The amygdala facilitates an individuals
  evaluation of threat or danger
• BPD patients with histories of childhood trauma
  have been shown to have hyperreactive amygdalar
  responses
• - Herpertz et al., Biol Psych
  50 292-298, 2001

3
Medial Prefrontal Cortex
Hippocampus
Amygdala
Hypothalamus
Orbital Prefrontal Cortex
Thalamus
4
(No Transcript)
5
Response to Facial Expressions

• BPD patients show significantly greater left
  amygdalar activation to facial expressions
  compared with normal controls
• BPD patients attribute negative qualities to
  neutral faces
• - Donegan et al 2003

6
Amygdala Hyperreactivity (Ekman Faces)
Activation map showing regions in the amygdala
slice in which activation exceeded the criterion
threshold level of Plt0.005 for the NC and BPD
groups for each of the 4 facial expressions.
NC normal control. - Donegan et
al. Biol Psych 2003541284
7
(No Transcript)
8
Amygdala Hyperreactivity
- Donegan et al., Biol Psych 2003541284
9
MR Volumetrics Orbitofrontal Cortex in BPD
L
16
15
14
13
Volume (cm3)
Volume (cm3)
12
11
10
9
8
L
R
Control
BPD
HC
BPD
- van Elst et al., Biol Psych 200354163
10
Bottom-Up Regulation of Emotion
AMYGDALA
REFLEXIVE/AUTOMATIC PROCESSES BOTTOM-UP
REGULATION
11
PREFRONTAL CORTEX TOP-DOWN REGULATION
AMYGDALA
REFLEXIVE/AUTOMATIC PROCESSES BOTTOM-UP
REGULATION
12
The Frontolimbic Network

• The frontolimbic network appears to be central to
  the emotional dysregulation in BPD
• This network consists of
• anterior cingulate cortex (ACC)
• orbitofrontal cortex (OFC)
• dorsolateral prefrontal cortex (DPC)
• hippocampus
• amygdala
• - Schmahl and Bremner, J
  Psych Res 40419-427, 2006

13
The Frontolimbic Network (cont.)

• ACC may be viewed as the brain region mediating
  emotion. Same brain areas are also involved in
  dysfunctional serotonergic transmission,
  associated with impulsive aggression in BPD
• The subgenual cingulate is involved with
  emotional control, and studies show that it is
  deactivated in response to stressful stimuli in
  BPD
• ACC dysfunction is probably a key factor in the
  emotional dysregulation seen in BPD
• 
  
  
• --Schmahl and Herpertz, J Psych Res 41419-427,
  2006

14
(No Transcript)
15
Frontolimbic Inhibitory Function

• BPD patients were asked to push a button for
  words in standard font but not for italicized
  words.
• BPD patients were more impulsive than controls,
  particularly when the italicized words were
  negative.
• In contrast to controls, BPD subjects showed ?
  amygdalar reaction and ? activity in subgenual
  cingulate and in medial OFC.
• - Silbersweig et al. Am J Psych 1641832-1841,
  2007

16
Frontolimbic Inhibitory Function(cont.)

• Also in response to negative words, BPD subjects
  showed ? activity in the dorsal ACC.
• Hence even though they were not able to exercise
  impulse control, they were aware they had to
  devote other resources to monitoring it.
• - Silbersweig et al. Am J Psych 1641832-1841,
  2007

17
(No Transcript)
18
Neuroimaging data of adult BPD patients suggest
that amygdalar hypersensitivity and emotional
dysregulationmay be related to specific
dysfunctionsin the prefrontal cortexand the ACC.

-Herpertz et al., Biol Psych 50 292-298,
2001-Donegan et al., Biol Psych 54
1284-1293,2003-Schmahl et al., Biol Psych 54
142-151, 2003
19
Heightened Emotional Sensitivity

• Misreading of neutral facial expressions is only
  part of the total picture.
• Women who are diagnosed as BPD actually can be
  more accurate in the labeling of fearful facial
  expressions than controls.
• - Wagner Linehan, J Personality Disorders
  13329-344, 1999

20
Heightened Emotional Sensitivity (cont.)

• Morphing of facial expressions is needed to
  accurately assess the capacity of BPD patients to
  respond to emotional expressions.
• Faces change gradually and monotonically from
  neutral to prototypical emotional expressions at
  maximum intensity.
• Allows assessment of how intense a facial
  expression must be before accurately recognized.
• - Lynch
  et al, Emotion 4647-655, 2006

21
Morphed Fear Faces Within Person
22
Heightened Emotional Sensitivity (cont.)

• 20 BPD subjects and 20 normal controls were
  compared on the morphing test.
• BPD patients correctly identified facial affect
  at an earlier stage than controls.
• - Lynch et al, Emotion
  4647-655, 2006

23
Heightened Emotional Sensitivity (cont.)

• BPD subjects were more sensitive than healthy
  controls in identifying the emotional expressions
  in general.
• Their results support the contention that
  heightened emotional sensitivity might be a core
  feature of BPD.
• Findings are consistent with emotional
  dysregulation as central to BPDthese patients
  overreact to relatively minor emotional
  expressions and interpersonal cues.
  

- Lynch et al, Emotion 4647-655, 2006
24

• How well do BPD patients mentalize?

25
Definition

• Mentalizing is a form of imaginative mental
  activity, namely, perceiving and interpreting
  human behavior in terms of mental states (e.g.,
  needs, desires, feelings, beliefs, goals,
  purposes, and reasons).

26

• Reading the Mind in the Eyes Test
• (RMET)

27
(No Transcript)
28
Reading Faces BPD

• 30 patients with BPD compared with 25 healthy
  controls using RMET
• BPD group performed significantly better than
  healthy controls.
• - Fertuck et al, American Psychoanalytic
  Association, 2009

29
(No Transcript)
30
Reading Faces BPD (cont.)

• Enhanced performance may be related to greater
  threat potential perceived in facial stimuli and
  hypervigilance.
• Neutral faces may represent the most ambiguous
  threat, so there is particular vigilance paid to
  neutral facial expressions.
• BPD subjects do particularly well compared with
  controls on neutral faces.
• - Fertuck et al,
  American Psychoanalytic Association, 2009
  

31
Reading Faces BPD (cont.)

• Perception of facial expressions is fairly
  accurate in patients with BPD.
• BPD patients have adapted to childhood trauma by
  assessing moment-to-moment shifts in the
  emotional state of others as a means of
  surviving.

32
Reading Faces BPD (cont.)

• The problem area for BPD lies in the
  interpretation of the emotional expression, not
  its perception, particularly of neutral or
  ambiguous states.
• The main difficulty appears to be assessing
  whether someone is trustworthy or notthey have
  difficulty linking trustworthiness with facial
  expression.

33
(No Transcript)
34
Reading Trustworthiness

• BPD group sees faces as less trustworthy than
  controls
• In contrast to trust, BPDs and controls read fear
  similarly
• BPD group takes longer to judge faces as more
  trustworthy also, shows more decision
  uncertainty
• 
  - Fertuck 2009

35
Paradox in the BPD Field

• The so-called radar for the therapists
  countertransference reflects the BPD patients
  heightened capacity to read early changes in
  facial expressions.
• However, co-existing with this capacity are
  misinterpretations that are quasi-delusional.

36
Donegan Subjects on Neutral Faces

• They look like mug shots, like someone who just
  got arrested
• They look fake, like a façadetheyre hiding
  something
• They look like they are plotting
  somethinguntrustworthy
• - Donegan, Biological
  Psychiatry, 2003

37
Paradox in the BPD Field (cont.)

• Heightened sensitivity may be both accurate and
  inaccurate.
• Accuracy probably varies depending on the state
  of the attachment relationship, the presence of
  powerful feelings, and the degree of ambiguity of
  the facial expression.

38
Paradox in the BPD Field (cont.)

• Mentalizing resides on a continuum from being
  accurate at some moments to absent at others.
• Mentalizing is intimately linked to the sense of
  being understood by an attachment figure, and BPD
  patients have trouble maintaining mentalization
  in the context of an intense attachment
  relationship. The attachment system is
  hypersensitive in BPD.
• 
  - Bateman Fonagy,
  2004

39
Clinical Implications

• Clinician needs to be aware that the patient may
  be accurately tuning in to a not-yet-conscious
  feeling state in the therapist.
• Clinicians must remember that neutral faces
  represent the most ambiguous threat.
• It is also possible that the patient may be
  misinterpreting and overreacting to a small
  change in facial expression.
• Therapists must be aware of nonverbal
  communications to patients.

40
Emotion Recognition

• BPD subjects have a bias towards the perception
  of anger, rejection, or social threat.
• They see the world and others as dangerous, and
  themselves as powerless and unacceptable.
• - Domes et al, J Personality
  Disorders 236-19, 2009

41
Emotion Recognition (cont.)

• Intact neurocircuitry within the amygdala is
  essential for intact emotion recognition.
• Patients with lesions of the amygdaloid complex
  show impaired recognition of negative facial
  expressions.
• 
  - Adolphs et al, Nature 43368-72, 2005
• - Domes
  et al, J Personality Disorders 236-19, 2009

42
Emotion Recognition (cont.)

• Functional imaging studies have found
  abnormalities in the prefrontal-amygdalar
  neurocircuitry mediating affect regulation in BPD
  subjects.
• In BPD interference between emotion and cognition
  has been demonstrated by several studies.
• Imaging studies suggest that BPD patients show
  structural and functional alterations in the
  fronto- limbic network, in particular reduced
  amygdalar volume and enhanced amygdalar
  responding to emotional stimuli.
• Domes et al, J
  Pers Diorders 236-19,2009

43
Emotion Recognition (cont.)

• Emotional arousal interferes with social or
  cognitive processing and might contribute to the
  characteristic alterations in facial emotion
  recognition.
• Maternal and romantic love activate an attachment
  system that may deactivate rational processing of
  feelings and perceptions of others.
• 
  - Bateman Fonagy, 2004

44
Indications of Attachment Hyperactivity in Core
Symptoms of BPD

• Pattern of unstable and intense interpersonal
  relationships
• Frantic efforts to avoid abandonment
• Rapidly escalating tempo, moving from
  acquaintance to great intimacy
• -
  Bateman Fonagy, 2004

45
Pre-Mentalizing Modes of Subjectivity in BPD
Psychic Equivalence Mode

• Mind-world isomorphism
• Mental reality external reality
• Intolerance of alternative perspectivesreality
  is how I see things.

46
Pre-Mentalizing Modes of Subjectivity in BPD
Psychic Equivalence (cont.)

• Perceived loss of attachment figure
• ? failure of mentalizing
• ? psychic equivalence
• ? intensification of unbearable affect
• ? self-harm or suicide attempt

47
Attachment Mentalizing

• Attachment and mentalization are loosely coupled
  systems existing in a state of partial
  exclusivity.
• Mentalization has its roots in the sense of being
  understood by an attachment figure.
• BPD is associated with hyperactive attachment
  systems as a result of early trauma and neglect.
• Rats placed with neglectful mothers are not
  calmed by her presence.
• 
  - Bateman Fonagy 2004 Nemeroff

48
Animals with Early Adverse Experience cannotuse
social support to buffer their stress responses
Mothers presence did not buffer physiological
response to stress of Abused infants in
comparison to Controls
The presence of a social companion buffers the
HPA response to stress. (Mat. Sep. monkeys lack
this buffering effect-not shown here)
49

• What is
• Mentalization-Based Therapy?

50

• An empirically validated therapy for MBT
• 8 year f/u study shows that it decreases need for
  inpatient stay, reduces suicidality, improves BPD
  symptoms and maintains gains compared to
  controls.
• -Bateman and Fonagy
  1999,2001,2008

51
Mentalization-Based Therapy

• Designed to stimulate the attachment system while
  helping patient maintain mentalizing
• Primary focus is on patients current mental
  state
• De-emphasizes deep unconscious concerns
• Recovery of mentalizing is more important than
  insight

52
Mentalization-Based Therapy (cont.)

• Avoid discussions of past trauma except in the
  context of reflecting on current perceptions of
  mental states and change in mental state as
  victim vs. the current experience
• Focus on patients mind rather than behavior
• Relate to current event or activity
• Use of therapists mind as model
• Active engagement with the patient

53
Mentalization-Based Therapy (cont.)

• Identify and praise positive mentalizing
• Promote curiosity about self and others through
  an inquisitive stance
• The mind of the patient is the focus of the
  treatment, so the therapist is cautious about
  telling the patient how he feels or thinks

54
Mentalization-Based Therapy (cont.)

• Therapist helps the patient generate multiple
  perspectives
• Therapist constructs an image of the patient
• Patients attention is focused on the therapists
  experience when it offers an opportunity to
  clarify misunderstandings

55

• HOW DOES
• E M P A T H Y
• DIFFER FROM
• MENTALIZATION?

56
Empathy vs. Mentalizing

• Empathy has three components
• An affective reaction that involves sharing of
  another persons emotional state
• A cognitive capacity to imagine other peoples
  perspectives
• A stable ability to maintain a self-other
  distinction
• - Choi-Kain
  Gunderson, Am J Psychiatry
• 
  1651127-1135, 2008

57
Empathy vs. Mentalizing

• Both involve appreciation of mental states in
  others
• Empathy adds the dimensions of sharing in those
  mental states and having empathic concern for
  others
• Empathy is more other-oriented while
  mentalization is equally self- and other-oriented
• Empathy involves cognitive skill and experience
  of affect, but its content is primarily
  affectively focused
• - Choi-Kain
  Gunderson, Am J Psychiatry
• 
  1651127-1135, 2008

58
Implicit Mentalization

• Unconscious, automatic, or procedural operations
  of an individuals ability to imagine his own and
  others mental states
• Taking turns in conversation

59
Explicit Mentalization

• Deliberately makes conscious efforts to know
  ones own and others internal experiences
• A therapist actively and consciously works to
  imagine the mental states of the patient and
  encourages the patient to do the same

60
Reflective functioning and BPD

• Reflective functioning (RF) is predictive of BPD
  diagnosis only in subjects with history of abuse
• Because RF varies depending on context, the
  assessment of mentalization as a marker of BPD
  remains problematic.
• - Choi-Kain Gunderson, Am J Psychiatry
  1651127-1135, 2008

61
(No Transcript)
62
Mirror Neurons Mentalization

• The fundamental mechanism that allows us to
  understand the actions and emotions of others
  involves the activation of the mirror neuron
  system for actions and the activation of
  viscero-motor centers for the understanding of
  affect.
• Action observation causes the automatic
  activation of the same neural mechanism triggered
  by action execution or even by the sound produced
  by the same action.
• - Gallese et al,
  Trends in Cognitive Science 8396-405, 2004
• 
  - Koehler et al, Science 97846-848, 2002

63
Mirror Neurons Mentalization (cont.)

• The 2-level system underpinning mentalization is
• A frontocorticol system involving cognitive
  interpretation of visual representations
• A mirror-neuron system subserving more immediate,
  direct understanding of the other
• The anterior insula mediates communication
  between the limbic system and mirror neurons we
  replay observed actions and react emotionally
• 
  - Wicker et al, Neuron 40655-664, 2003

64
(No Transcript)
65
Mirror Neurons Mentalization (cont.)

• The inhibition of imitative behavior involves
  cortical areas related to mentalizing.
• This allows us to differentiate self and other.
• It is not the mirror system per se that is
  related to mentalizing, but rather the control of
  the mirror system.
• 
  -
  Fonagy 2009
• - Brass Haggard,
  Neuroscientist 14319-325, 2008

66
CONCLUSIONS

• BPD patients are unusually perceptive but tend to
  misinterpret trustworthiness
• Mentalizing exists on a continuum and is highly
  variable in BPD

67
CONCLUSIONS

• Therapists must take into account BOTH the
  possibility of accurate perception of unconscious
  emotion in the therapist AND the
  transference-based misinterpretation of those
  perceptions