Neurophysiology of Borderline Personality Disorder

Borderline Personality Disorder (BPD) isn’t just about emotions and behaviors. It involves how our brain functions. There is a complex interaction of different structures of the brain with different neurotransmitters. The way the structures in the brain interact with different neurotransmitters produces an array of complex interaction and functional pathway that determines how we think behave and feel. The same dynamics when disrupted produces changes in the pattern of behaviors and thought that underly different mental illnesses similar to Borderline Personality Disorder.

The diagnoses of Borderline Personality Disorder is based on DSM Criteria.

Brain Structures

BPD is a severe psychiatric disorder characterized by instability of interpersonal relationships, self-image, and affect, as well as impulsivity.¹¹ It is associated with high risk behavior including impulsive and potentially self-harming actions such as unsafe sex, substance use, reckless driving, nonsuicidal self-injury (NSSI) and suicidal behavior. Over 70% of patients with BPD report a history of multiple episodes and methods of NSSI, while 60% report multiple suicide attempts.¹² Individuals with BPD tend to utilize mental health care services at a high rate.¹³ BPD occurs in 0.5%−5.9% of the general US population, 8%−18% of psychiatric outpatients and 6.5%−42.7% of psychiatric inpatients.^14-18 BPD is highly comorbid with mood (50.9%), anxiety (59.6%), substance use (50.7%), and other personality disorders (73.9%).^14,15,17 The rate of co-occurring PTSD in individuals with BPD is approximately 30% in community samples.^15,16

Most of the studies find brain regions involved in emotional processing such as the amygdala, insula, posterior cingulate cortex, hippocampus, anterior cingulate cortex, and prefrontal regulatory regions including the orbital frontal cortex, dorsal lateral prefrontal cortex, and ventral lateral prefrontal cortex are involved in BPD.

1. Amygdala
   • Amygdala is a structure in the temporal lobe of human brain. These are almond shaped structures which play a crucial role in the processing memory, decision-making, and emotional responses (including fear, anxiety, and aggression). Amygdala was first identified and named by Karl Friedrich Burdach in 1822 (Pabba M, 2013).
   • It has been found that people with BPD have an excess of activity in the left amygdala especially when faced with negative emotional stimuli. This is also resonated in the left hippocampus, insula and posterior cingulate cortex and a diminished activation in the prefrontal regions including dorsal lateral prefrontal cortex. This leads to a heightened emotional reactions and difficulties in regulating emotions.
   • In a metanalytical study (Ruocco AC, 2013) left amygdala and right hippocampus gray volume decrease were noted in BPD patients.
   • Dialectical Behavior Therapy (DBT) was found to increase of measure in emotional regulation which also attenuated amygdaloid hyperactivity.
2. Prefrontal Regulatory Networks
   1. Functional connectivity among the brain regions are studied using seed-based correlations. Three networks come out as salient.
      1. The Default Mode: This network is activated when the brain is at rest and is mediated by medial prefrontal cortex and posterior cingulate cortex. The default mode activates self-referential thinking.
      2. The Salience Network includes the orbital frontal insula and the dorsal anterior cingulate cortex.
      3. The Medial Temporal Lobe Network is responsible for processing negative emotions.
   2. In Borderline Personality Disorder there seems to be an erroneous connectivity between salience detection and self-referential encoding.
   3. Functional connectivity whithin the frontolimbic pathways relate to severeity of symptoms such as affective instability, avoidance of abandonment and anger according to a study (Krause-Utz A, 2014)
3. Prefrontal Cortex
   • The prefrontal cortex, particularly the orbitofrontal cortex, plays a critical role in decision-making, impulse control, and regulating emotional responses.
   • People with BPD frequently exhibit hypoactivity in the prefrontal cortex, contributing to impulsivity, poor decision-making, and emotional dysregulation.
4. Hippocampus
   • The hippocampus is essential for memory formation and emotional regulation.
   • Research has indicated that individuals with BPD may have a smaller hippocampal volume, which could be related to the intense and unstable emotions experienced in BPD.
5. Anterior Cingulate Cortex
   • The anterior cingulate cortex (ACC) is involved in emotional processing and regulation.
   • Abnormalities in the ACC have been linked to the mood instability and difficulties in emotional control seen in BPD
   • The Anterior Cingulate Cortex is a key region associated with BPD. ACC is necessary for the production of distress calls due to maternal separation (MacLean and Newman, 1988). ACC is also activated in human adults during experience of social rejection (Eisenberger et al., 2003). These phenomenon are very much related to the clinical characteristics of BPD characterized by fear of abandonment, sensitivity to social attachment, rejection sensitivity and emotion dysregulations (Lieb et al., 2004)

Neurotransmitter Systems

1. Serotonin
   • Serotonin is a neurotransmitter that plays a significant role in mood regulation, impulse control, and aggression.
   • Dysregulation of the serotonergic system in BPD can lead to impulsive behaviors, mood swings, and aggression.
2. Dopamine
   • Dopamine is associated with reward processing, motivation, and emotional regulation.
   • Altered dopamine functioning in individuals with BPD can contribute to impulsivity, mood dysregulation, and difficulties in experiencing pleasure.
3. Norepinephrine
   • Norepinephrine is involved in the body’s stress response and regulation of arousal and alertness.
   • Elevated levels of norepinephrine in BPD patients can exacerbate symptoms of anxiety and emotional instability.

Functional Connectivity

1. Emotion Regulation Networks
   • Functional connectivity studies have shown that individuals with BPD often have disrupted connectivity between the amygdala and the prefrontal cortex.
   • This disruption can impair the ability to regulate emotions effectively, leading to the intense and unstable emotions characteristic of BPD.
2. Default Mode Network
   • The default mode network (DMN) is active during rest and self-referential thought processes.
   • Abnormal connectivity within the DMN in BPD patients can lead to problems with self-identity and self-image, contributing to the unstable sense of self often seen in BPD.
3. Salience Network
   • The salience network helps to identify and respond to important stimuli.
   • Hyperactivity in the salience network can cause individuals with BPD to perceive social and emotional cues as more intense or threatening than they are, leading to heightened emotional responses and interpersonal difficulties.

Conclusion

The neurophysiology of Borderline Personality Disorder involves complex interactions between various brain structures and neurotransmitter systems. Hyperactivity in the amygdala, hypoactivity in the prefrontal cortex, and abnormalities in the hippocampus and anterior cingulate cortex contribute to the emotional instability, impulsivity, and difficulties in self-regulation experienced by individuals with BPD. Dysregulation of neurotransmitter systems, including serotonin, dopamine, and norepinephrine, further exacerbates these symptoms. Understanding these neurophysiological factors is crucial for developing targeted treatments and interventions to help individuals with BPD manage their symptoms and improve their quality of life.

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Borderline Personality Disorder | Psychology Nepal

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