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Schubert CF, Schreckenbach M, Kirmeier T, Gall-Kleebach DJ, Wollweber B, Buell DR, Uhr M, Rosner R, Schmidt U. PTSD psychotherapy improves blood pressure but leaves HPA axis feedback sensitivity stable and unaffected: First evidence from a pre-post treatment study. Psychoneuroendocrinology 2019; 100:254-263. [PMID: 30391833 DOI: 10.1016/j.psyneuen.2018.10.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 10/15/2018] [Accepted: 10/15/2018] [Indexed: 01/05/2023]
Abstract
Although key to development of tailored drugs for augmentation treatment of psychotherapy for posttraumatic stress disorder (PTSD), the biological correlates of PTSD remission are still unknown, probably because pre-post treatment studies searching for them are rare. Not even the feedback sensitivity of the otherwise well-studied hypothalamic-pituitary-adrenal (HPA) axis nor arterial blood pressure (BP), which was previously reported to be elevated in PTSD patients, have so far been analyzed during PTSD treatment. To narrow this knowledge gap, we first performed an overnight dexamethasone suppression test (DST) in a mixed-sex cohort of 25 patients with severe PTSD vs. 20 non-traumatized healthy controls (nt-HC). In addition to hormones, BP and heart rate (HR) were measured at each of the four assessment points (APs). Second, the same parameters were assessed again in 16 of these patients after 12 sessions of integrative trauma-focused cognitive behavioral therapy (iTF-CBT). In relation to nt-HC, PTSD patients showed a significant elevation in HR and diastolic BP while their systolic BP, DST outcomes and basal serum cortisol levels (BSCL) were not significantly altered. In response to iTF-CBT, PTSD symptoms and dysfunctional stress coping strategies improved significantly in PTSD patients. Most important, also their systolic and diastolic BP levels ameliorated at distinct APs while their DST outcomes and BSCL remained unchanged. To our knowledge, this is the first pre-post treatment study assessing the stability of the DST outcome and BP levels during PTSD treatment. Our results provide first evidence for a non-involvement of HPA axis feedback sensitivity in PTSD symptom improvement and, furthermore, suggest a possible role for BP-regulating pathways such as the sympathetic nervous system in PTSD remission. Limitations arise from the small sample size, the lack of an untreated patient group and drug treatment of patients.
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Affiliation(s)
- Christine F Schubert
- Max Planck Institute of Psychiatry, Department of Translational Psychiatry, RG Molecular Psychotraumatology, Kraepelinstrasse 10, 80804 Munich, Germany; Catholic University of Eichstätt-Ingolstadt, Ostenstraße 25, 85072 Eichstätt, Germany; Ludwig Maximilians University, Department of Psychology, Leopoldstraße 44, 80802 Munich, Germany
| | - Monika Schreckenbach
- Max Planck Institute of Psychiatry, Department of Translational Psychiatry, RG Molecular Psychotraumatology, Kraepelinstrasse 10, 80804 Munich, Germany
| | | | - Dominique J Gall-Kleebach
- Max Planck Institute of Psychiatry, Department of Translational Psychiatry, RG Molecular Psychotraumatology, Kraepelinstrasse 10, 80804 Munich, Germany; Verein für Klinische Verhaltenstherapie (VFKV) - Ausbildungsinstitut München gGmbH, Lindwurmstr. 117, 80337 München, Germany
| | - Bastian Wollweber
- Max Planck Institute of Psychiatry, Department of Translational Psychiatry, RG Molecular Psychotraumatology, Kraepelinstrasse 10, 80804 Munich, Germany
| | - Dominik R Buell
- Max Planck Institute of Psychiatry, Department of Translational Psychiatry, RG Molecular Psychotraumatology, Kraepelinstrasse 10, 80804 Munich, Germany
| | - Manfred Uhr
- Max Planck Institute of Psychiatry, Clinical Department, Kraepelinstrasse 10, 80804 Munich, Germany
| | - Rita Rosner
- Catholic University of Eichstätt-Ingolstadt, Ostenstraße 25, 85072 Eichstätt, Germany
| | - Ulrike Schmidt
- Max Planck Institute of Psychiatry, Department of Translational Psychiatry, RG Molecular Psychotraumatology, Kraepelinstrasse 10, 80804 Munich, Germany; University Medical Center Göttingen (UMG), Department of Psychiatry and Psychotherapy, Psychotrauma Treatment Unit & RG Stress Modulation of Neurodegeneration, Göttingen, Germany; Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands.
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Willemsen RH, van Leeuwen L, Voorend-van Bergen TAS, de Rijke YB, Pijnenburg MW, van den Akker ELT. Reproducibility and utility of an overnight 0.25 mg dexamethasone suppression test as a marker for glucocorticoid sensitivity in children with asthma. J Endocrinol Invest 2016; 39:93-6. [PMID: 26059835 PMCID: PMC4703608 DOI: 10.1007/s40618-015-0323-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 05/22/2015] [Indexed: 11/08/2022]
Abstract
PURPOSE Inhaled corticosteroids (ICS) are the cornerstone of asthma treatment in children. However, there is considerable inter-individual variation in glucocorticoid sensitivity, leading to over- as well as undertreatment. A simple and fast test to predict glucocorticoid sensitivity would enable more tailored therapy in children with asthma. AIM To study reproducibility and utility of an overnight 0.25 mg dexamethasone suppression test (DST) with salivary cortisol levels as marker for glucocorticoid sensitivity in asthmatic children. METHODS 23 children with atopic asthma were recruited for two overnight 0.25 mg DST's, 1 month apart. RESULTS Baseline cortisol levels correlated well between both tests. However, cortisol levels, change in cortisol levels or fractional suppression of cortisol levels after dexamethasone did not correlate between the two tests. Bland-Altman plots showed that the difference in salivary cortisol levels between test 1 and 2 of an individual patient could go up to 12 nmol/l, which is a clinically relevant difference. ICS dose did not correlate with baseline cortisol levels, height and BMI SDS. CONCLUSION The low-dose salivary DST test in its current form is not suitable for use in clinical practice in children with asthma, due to low reproducibility. Therefore, studies using the 0.25 mg salivary DST should be interpreted cautiously.
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Affiliation(s)
- R H Willemsen
- Department of Paediatric Endocrinology, Erasmus MC Sophia, 3015 GJ, Rotterdam, The Netherlands.
- Department of Paediatrics, Box 116 Level 8 Addenbrooke's Hospital, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
| | - L van Leeuwen
- Department of Paediatric Endocrinology, Erasmus MC Sophia, 3015 GJ, Rotterdam, The Netherlands
| | | | - Y B de Rijke
- Diagnostic Laboratory Endocrinology, Departments of Clinical Chemistry and Internal Medicine, Erasmus MC, 3015 GJ, Rotterdam, The Netherlands
| | - M W Pijnenburg
- Department of Paediatric Pulmonology, Erasmus MC Sophia, 3015 GJ, Rotterdam, The Netherlands
| | - E L T van den Akker
- Department of Paediatric Endocrinology, Erasmus MC Sophia, 3015 GJ, Rotterdam, The Netherlands
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Fischer A, Grundmann J, Gold SM, Spitzer C, Wingenfeld K. Steroid regulation of T cell function appears unaltered in borderline personality disorder. J Pers Disord 2015; 29:241-7. [PMID: 25248018 DOI: 10.1521/pedi_2014_28_156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Borderline personality disorder (BPD) is characterized by instability of interpersonal relationships and affection, impulsivity, and cognitive disruptions. Increasing evidence suggests hypothalamic-pituitary-adrenal (HPA) axis alterations in BPD. Changed glucocorticoid sensitivity of peripheral blood mononuclear cells is known in mood and posttraumatic stress disorders, representing frequent comorbidities in BPD. However, to the authors' knowledge, in BPD glucocorticoid sensitivity at the receptor level remains unexplored. Sixteen age-matched female BPD patients were compared to sixteen female healthy controls. In vitro steroid sensitivity of T cell proliferation was tested using aldosterone, dexamethasone, and hydrocortisone. Steroid sensitivity of BPD patients and healthy controls appeared comparable. Psychiatric comorbidities such as major depressive disorder or posttraumatic stress disorder and early life stress seemed to have had no influence on steroid sensitivity parameters. The data suggest unaltered GC sensitivity of T cell function in BPD.
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Frías Á, Palma C. Comorbidity between post-traumatic stress disorder and borderline personality disorder: a review. Psychopathology 2015; 48:1-10. [PMID: 25227722 DOI: 10.1159/000363145] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 04/13/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Traditionally, the presence of post-traumatic stress disorder (PTSD) in subjects diagnosed with borderline personality disorder (BPD) has been the object of scant empirical research. The clarification of issues related to the different areas of study for this comorbidity is not only significant from a theoretical point of view but also relevant for clinical practice. The aim of this review is to describe the main theoretical findings and research conclusions about the comorbidity between PTSD and BPD. METHODS A literature review was carried out via PubMed and PsycINFO for the period between 1990 and September 2013. The descriptors used were 'post-traumatic stress disorder', 'borderline personality disorder', 'PTSD', 'complex PTSD' and 'BPD'. RESULTS Epidemiological studies show that the risk of PTSD among BPD subjects is not regularly higher than in subjects with other personality disorders. Furthermore, there is no conclusive evidence about the main aetiopathogenic mechanism of this comorbidity, either of one disorder being a risk factor for the other one or of common underlying variables. Concerning comparative studies, several studies with PTSD-BPD subjects have found a higher severity of psychopathology and psychosocial impairment than in BPD subjects. With regard to nosological status, the main focus of controversy is the validation of 'complex PTSD', a clinical entity which may comprise a subgroup of PTSD-BPD subjects. With regard to treatment, there are preliminary evidences for the efficient treatment of psychopathology in both PTSD and BPD. CONCLUSIONS These findings are remarkable for furthering the understanding of the link between PTSD and BPD and their implications for treatment. The results of this review are discussed, including methodological constraints that hinder external validity and consistency of referred findings.
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Affiliation(s)
- Álvaro Frías
- FPCEE Blanquerna, University of Ramon-Llull, Barcelona, Spain
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Amad A, Ramoz N, Thomas P, Jardri R, Gorwood P. Genetics of borderline personality disorder: systematic review and proposal of an integrative model. Neurosci Biobehav Rev 2014; 40:6-19. [PMID: 24456942 DOI: 10.1016/j.neubiorev.2014.01.003] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 12/13/2013] [Accepted: 01/09/2014] [Indexed: 12/31/2022]
Abstract
Borderline personality disorder (BPD) is one of the most common mental disorders and is characterized by a pervasive pattern of emotional lability, impulsivity, interpersonal difficulties, identity disturbances, and disturbed cognition. Here, we performed a systematic review of the literature concerning the genetics of BPD, including familial and twin studies, association studies, and gene-environment interaction studies. Moreover, meta-analyses were performed when at least two case-control studies testing the same polymorphism were available. For each gene variant, a pooled odds ratio (OR) was calculated using fixed or random effects models. Familial and twin studies largely support the potential role of a genetic vulnerability at the root of BPD, with an estimated heritability of approximately 40%. Moreover, there is evidence for both gene-environment interactions and correlations. However, association studies for BPD are sparse, making it difficult to draw clear conclusions. According to our meta-analysis, no significant associations were found for the serotonin transporter gene, the tryptophan hydroxylase 1 gene, or the serotonin 1B receptor gene. We hypothesize that such a discrepancy (negative association studies but high heritability of the disorder) could be understandable through a paradigm shift, in which "plasticity" genes (rather than "vulnerability" genes) would be involved. Such a framework postulates a balance between positive and negative events, which interact with plasticity genes in the genesis of BPD.
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Affiliation(s)
- Ali Amad
- Univ Lille Nord de France, CHRU de Lille, F-59000 Lille, France; Laboratoire de Neurosciences Fonctionnelles et Pathologies (LNFP), Université Droit & Santé Lille (UDSL), F-59000 Lille, France; Psychiatry and Pediatric Psychiatry Department, University Medical Centre of Lille (CHULille), F-59037 Lille, France.
| | - Nicolas Ramoz
- INSERM U894, Centre de Psychiatrie & Neurosciences, Paris, France
| | - Pierre Thomas
- Univ Lille Nord de France, CHRU de Lille, F-59000 Lille, France; Laboratoire de Neurosciences Fonctionnelles et Pathologies (LNFP), Université Droit & Santé Lille (UDSL), F-59000 Lille, France; Psychiatry and Pediatric Psychiatry Department, University Medical Centre of Lille (CHULille), F-59037 Lille, France
| | - Renaud Jardri
- Univ Lille Nord de France, CHRU de Lille, F-59000 Lille, France; Laboratoire de Neurosciences Fonctionnelles et Pathologies (LNFP), Université Droit & Santé Lille (UDSL), F-59000 Lille, France; Psychiatry and Pediatric Psychiatry Department, University Medical Centre of Lille (CHULille), F-59037 Lille, France
| | - Philip Gorwood
- INSERM U894, Centre de Psychiatrie & Neurosciences, Paris, France; Sainte-Anne Hospital (Paris-Descartes University), Paris, France
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Ford JD, Courtois CA. Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personal Disord Emot Dysregul 2014; 1:9. [PMID: 26401293 PMCID: PMC4579513 DOI: 10.1186/2051-6673-1-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 05/18/2014] [Indexed: 12/23/2022] Open
Abstract
Complex PTSD (cPTSD) was formulated to include, in addition to the core PTSD symptoms, dysregulation in three psychobiological areas: (1) emotion processing, (2) self-organization (including bodily integrity), and (3) relational security. The overlap of diagnostic criteria for cPTSD and borderline personality disorder (BPD) raises questions about the scientific integrity and clinical utility of the cPTSD construct/diagnosis, as well as opportunities to achieve an increasingly nuanced understanding of the role of psychological trauma in BPD. We review clinical and scientific findings regarding comorbidity, clinical phenomenology and neurobiology of BPD, PTSD, and cPTSD, and the role of traumatic victimization (in general and specific to primary caregivers), dissociation, and affect dysregulation. Findings suggest that BPD may involve heterogeneity related to psychological trauma that includes, but extends beyond, comorbidity with PTSD and potentially involves childhood victimization-related dissociation and affect dysregulation consistent with cPTSD. Although BPD and cPTSD overlap substantially, it is unwarranted to conceptualize cPTSD either as a replacement for BPD, or simply as a sub-type of BPD. We conclude with implications for clinical practice and scientific research based on a better differentiated view of cPTSD, BPD and PTSD.
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Affiliation(s)
- Julian D Ford
- University of Connecticut Health Center MC1410, 263 Farmington Avenue, Farmington, CT 06030-1410 USA
| | - Christine A Courtois
- Independent Pactice, Washington, DC, Elements Behavioral Health, Promises, Malibu, CA USA
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Wingenfeld K, Driessen M, Terfehr K, Schlosser N, Fernando SC, Otte C, Beblo T, Spitzer C, Löwe B, Wolf OT. Effects of cortisol on memory in women with borderline personality disorder: role of co-morbid post-traumatic stress disorder and major depression. Psychol Med 2013; 43:495-505. [PMID: 23171911 DOI: 10.1017/s0033291712001961] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Stress and cortisol administration are known to have impairing effects on memory retrieval in healthy humans. These effects are reported to be altered in patients with major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) but they have not yet been investigated in borderline personality disorder (BPD). METHOD In a placebo-controlled cross-over study, 71 women with BPD and 40 healthy controls received either placebo or 10 mg of hydrocortisone orally before undertaking a declarative memory retrieval task (word list learning) and an autobiographical memory test (AMT). A working memory test was also applied. RESULTS Overall, opposing effects of cortisol on memory were observed when comparing patients with controls. In controls, cortisol had impairing effects on memory retrieval whereas in BPD patients cortisol had enhancing effects on memory retrieval of words, autobiographical memory and working memory. These effects were most pronounced for specificity of autobiographical memory retrieval. Patients with BPD alone and those with co-morbid PTSD showed this effect. We also found that co-morbid MDD influenced the cortisol effects: in this subgroup (BPD + MDD) the effects of cortisol on memory were absent. CONCLUSIONS The present results demonstrate beneficial effects of acute cortisol elevations on hippocampal-mediated memory processes in BPD. The absence of these effects in patients with co-morbid MDD suggests that these patients differ from other BPD patients in terms of their sensitivity to glucocorticoids (GCs).
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Affiliation(s)
- K Wingenfeld
- Department of Psychiatry and Psychotherapy, Charité University Berlin, Campus Benjamin Franklin, Berlin, Germany.
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Golden SH, Wand GS, Malhotra S, Kamel I, Horton K. Reliability of hypothalamic-pituitary-adrenal axis assessment methods for use in population-based studies. Eur J Epidemiol 2011; 26:511-25. [PMID: 21533585 DOI: 10.1007/s10654-011-9585-2] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 04/12/2011] [Indexed: 01/30/2023]
Abstract
Population-based studies have been hampered in exploring hypothalamic-pituitary-adrenal axis (HPA) activity as a potential explanatory link between stress-related and metabolic disorders due to their lack of incorporation of reliable measures of chronic cortisol exposure. The purpose of this review is to summarize current literature on the reliability of HPA axis measures and to discuss the feasibility of performing them in population-based studies. We identified articles through PubMed using search terms related to cortisol, HPA axis, adrenal imaging, and reliability. The diurnal salivary cortisol curve (generated from multiple salivary samples from awakening to midnight) and 11 p.m. salivary cortisol had the highest between-visit reliabilities (r = 0.63-0.84 and 0.78, respectively). The cortisol awakening response and dexamethasone-suppressed cortisol had the next highest between-visit reliabilities (r = 0.33-0.67 and 0.42-0.66, respectively). Based on our own data, the inter-reader reliability (r(s)) of adrenal gland volume from non-contrast CT was 0.67-0.71 for the left and 0.47-0.70 for the right adrenal glands. While a single 8 a.m. salivary cortisol is one of the easiest measures to perform, it had the lowest between-visit reliability (R = 0.18-0.47). Based on the current literature, use of sampling multiple salivary cortisol measures across the diurnal curve (with awakening cortisol), dexamethasone-suppressed cortisol, and adrenal gland volume are measures of HPA axis tone with similar between-visit reliabilities which likely reflect chronic cortisol burden and are feasible to perform in population-based studies.
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Pagura J, Stein MB, Bolton JM, Cox BJ, Grant B, Sareen J. Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population. J Psychiatr Res 2010; 44:1190-8. [PMID: 20537660 PMCID: PMC4209725 DOI: 10.1016/j.jpsychires.2010.04.016] [Citation(s) in RCA: 158] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Revised: 04/02/2010] [Accepted: 04/14/2010] [Indexed: 11/16/2022]
Abstract
While placed on different axes of the DSM classification system, borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) have important relationships with trauma, and overlap between these disorders has long been recognized. The current study is the first to examine comorbidity of PTSD and BPD in a large nationally representative sample using a reliable and valid method of assessing Axis I and II mental disorders. Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave II (N = 34,653; response rate 70.2%). Multiple regression models were used to examine differences in psychopathology, traumatic events and health-related quality of life across individuals with PTSD alone (n = 1820), BPD alone (n = 1290) and those with comorbid PTSD-BPD (n = 643). The lifetime prevalence of PTSD and BPD were 6.6% and 5.9%, respectively. Of individuals with BPD, 30.2% were also diagnosed with PTSD, whereas 24.2% of individuals with PTSD were also diagnosed with BPD. Individuals with comorbid PTSD-BPD had a poorer quality of life, more comorbidity with other Axis I conditions, increased odds of a lifetime suicide attempt, and a higher prevalence of repeated childhood traumatic events than individuals with either condition alone. These results show that PTSD and BPD have a high degree of lifetime co-occurrence but are not entirely overlapping. Their concurrence is associated with poorer functioning compared to either diagnosis alone, emphasizing the clinical utility of diagnosing both conditions. Future research should explore the determinants of having either or both diagnoses with an aim toward improved identification, prevention, and intervention.
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Affiliation(s)
- Jina Pagura
- Department of Psychology, University of Manitoba,Department of Psychiatry, University of Manitoba
| | - Murray B. Stein
- Departments of Psychiatry and Family & Preventive Medicine, University of California, San Diego
| | | | - Brian J. Cox
- Department of Psychology, University of Manitoba,Department of Psychiatry, University of Manitoba,Department of Community Health Sciences, University of Manitoba
| | - Bridget Grant
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National, Institutes of Health, Bethesda, MD, USA
| | - Jitender Sareen
- Department of Psychiatry, University of Manitoba,Department of Community Health Sciences, University of Manitoba,Corresponding Author: Jitender Sareen MD, Department of Psychiatry, University of Manitoba, PZ-430 771 Bannatyne Ave, Winnipeg Manitoba, R3E 3N4, Ph: 204.787.7078; Fax: 204.787.4879,
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Wingenfeld K, Spitzer C, Rullkötter N, Löwe B. Borderline personality disorder: hypothalamus pituitary adrenal axis and findings from neuroimaging studies. Psychoneuroendocrinology 2010; 35:154-70. [PMID: 19837517 DOI: 10.1016/j.psyneuen.2009.09.014] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Revised: 08/31/2009] [Accepted: 09/14/2009] [Indexed: 01/24/2023]
Abstract
Borderline personality disorder (BPD) is a complex and serious mental disorder that is commonly seen psychiatric practice. Although stress, especially early life stress, seems to be associated with the development of the disorder, there has been far less research on the function of the hypothalamic-pituitary-adrenal (HPA) axis in BPD, compared to other psychiatric disorders, such as major depressive disorder and post-traumatic stress disorder. Stress has been suggested to exert damaging effects on the brain, particularly the hippocampus; therefore, neuroimaging studies yield important insight into the neurobiology of BPD. This article reviews research on the HPA axis and neuroimaging studies in BPD and aims to integrate these findings.
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Affiliation(s)
- Katja Wingenfeld
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & Schön Klinik Hamburg-Eilbek, 20246 Hamburg, Germany.
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A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Dev Psychopathol 2009; 21:1355-81. [PMID: 19825272 DOI: 10.1017/s0954579409990198] [Citation(s) in RCA: 485] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractThe precise nature and etiopathogenesis of borderline personality disorder (BPD) continues to elude researchers and clinicians. Yet, increasing evidence from various strands of research converges to suggest that affect dysregulation, impulsivity, and unstable relationships constitute the core features of BPD. Over the last two decades, the mentalization-based approach to BPD has attempted to provide a theoretically consistent way of conceptualizing the interrelationship between these core features of BPD, with the aim of providing clinicians with a conceptually sound and empirically supported approach to BPD and its treatment. This paper presents an extended version of this approach to BPD based on recently accumulated data. In particular, we suggest that the core features of BPD reflect impairments in different facets of mentalization, each related to impairments in relatively distinct neural circuits underlying these facets. Hence, we provide a comprehensive account of BPD by showing how its core features are related to each other in theoretically meaningful ways. More specifically, we argue that BPD is primarily associated with a low threshold for the activation of the attachment system and deactivation of controlled mentalization, linked to impairments in the ability to differentiate mental states of self and other, which lead to hypersensitivity and increased susceptibility to contagion by other people's mental states, and poor integration of cognitive and affective aspects of mentalization. The combination of these impairments may explain BPD patients' propensity for vicious interpersonal cycles, and their high levels of affect dysregulation and impulsivity. Finally, the implications of this expanded mentalization-based approach to BPD for mentalization-based treatment and treatment of BPD more generally are discussed.
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Zimmerman DJ, Choi-Kain LW. The hypothalamic-pituitary-adrenal axis in borderline personality disorder: a review. Harv Rev Psychiatry 2009; 17:167-83. [PMID: 19499417 DOI: 10.1080/10673220902996734] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND borderline personality disorder (BPD) is a psychiatric diagnosis characterized by high exposure, reactivity, and vulnerability to stress. Given these abnormalities in stress reactivity in BPD, there is a question of whether the hypothalamic-pituitary-adrenal (HPA) axis functions normally in BPD, since the activation of the HPA axis normally occurs to coordinate both behavioral and physiologic responses to stress. Several studies have investigated the functioning of the HPA axis in BPD and have shown varied results. This review seeks to summarize and interpret the findings of this growing literature. METHODS Pubmed search for English language articles on borderline personality disorder and hypothalamic-pituitary-adrenal axis. RESULTS findings are mixed but suggest that important variables relevant to between-group differences include comorbid depression, comorbid posttraumatic stress disorder, dissociative symptoms, and history of childhood abuse. DISCUSSION comorbid diagnoses and clinical features such as trauma history and symptom severity may have variable, interacting influences on the psychoneuroendocrine profile in BPD. Also explored here are the implications of these findings for developing possible models of HPA-axis dysfunction in BPD, for identifying potential targets for treatment, and for improving the methodology of future studies.
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Affiliation(s)
- Daniel J Zimmerman
- Department of Psychiatry, Harvard Medical School, McLean Hospital, Belmont, MA 02478, USA
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