Heightened Emotional Sensitivity and Transference in BPD

Heightened Emotional Sensitivity and Transference in BPD

Glen O. Gabbard, M.D.Glen O. Gabbard, M.D.

Brown Foundation Chair of PsychoanalysisBrown Foundation Chair of Psychoanalysis

&&

Professor of PsychiatryProfessor of Psychiatry

Baylor College of Medicine Baylor College of Medicine

Training & Supervising Analyst Training & Supervising Analyst

Houston-Galveston Psychoanalytic Institute Houston-Galveston Psychoanalytic Institute

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The Role of the AmygdalaThe Role of the Amygdala

The amygdala increases vigilanceThe amygdala increases vigilance

The amygdala facilitates an individual’s The amygdala facilitates an individual’s evaluation of threat or dangerevaluation of threat or danger

BPD patients with histories of BPD patients with histories of childhood trauma have been shown to childhood trauma have been shown to have hyperreactive amygdalar have hyperreactive amygdalar responsesresponses

- Herpertz et al., - Herpertz et al., Biol PsychBiol Psych 50: 292-298, 2001 50: 292-298, 2001

Hippocampus

Thalamus

AmygdalaMedial PrefrontalCortex

Hypothalamus Orbital PrefrontalCortex

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Response to Facial ExpressionsResponse to Facial Expressions

BPD patients show significantly BPD patients show significantly greater left amygdalar activation to greater left amygdalar activation to facial expressions compared with facial expressions compared with normal controlsnormal controls

BPD patients attribute negative BPD patients attribute negative qualities to neutral facesqualities to neutral faces

- Donegan et al 2003- Donegan et al 2003

Amygdala Hyperreactivity Amygdala Hyperreactivity (Ekman Faces)(Ekman Faces)

NC = normal control. - Donegan et al. Biol Psych 2003;54:1284

Activation map showing regions in the amygdala slice in which activation exceeded the criterion threshold level of P<0.005 for the NC and BPD groups for each of the 4 facial expressions.

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Amygdala HyperreactivityAmygdala Hyperreactivity

- Donegan et al., Biol Psych 2003;54:1284

Neutral Happy Sad FearfulBPDNCBPDNCBPDNCBPDNC

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MR Volumetrics: Orbitofrontal MR Volumetrics: Orbitofrontal Cortex in BPDCortex in BPD

- van Elst et al., Biol Psych 2003;54:163

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AMYGDALA

REFLEXIVE/AUTOMATIC PROCESSES:

“BOTTOM-UP” REGULATION

“Bottom-Up” Regulation of Emotion

AMYGDALA

PREFRONTAL CORTEX:“TOP-DOWN” REGULATION

REFLEXIVE/AUTOMATIC PROCESSES:

“BOTTOM-UP” REGULATION

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The Frontolimbic NetworkThe Frontolimbic Network

The frontolimbic network appears to be The frontolimbic network appears to be central to the emotional dysregulation in central to the emotional dysregulation in BPDBPDThis network consists of:This network consists of:

anterior cingulate cortex (ACC)anterior cingulate cortex (ACC)orbitofrontal cortex (OFC)orbitofrontal cortex (OFC)dorsolateral prefrontal cortex (DPC)dorsolateral prefrontal cortex (DPC)hippocampushippocampusamygdalaamygdala

- - Schmahl and Bremner, Schmahl and Bremner, J Psych ResJ Psych Res 40:419-427, 200640:419-427, 2006

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The Frontolimbic NetworkThe Frontolimbic Network (cont.)(cont.)

ACC may be viewed as the brain region ACC may be viewed as the brain region mediating emotion. Same brain areas are also mediating emotion. Same brain areas are also involved in dysfunctional serotonergic involved in dysfunctional serotonergic transmission, associated with impulsive transmission, associated with impulsive aggression in BPDaggression in BPDThe subgenual cingulate is involved with The subgenual cingulate is involved with emotional control, and studies show that it is emotional control, and studies show that it is deactivated in response to stressful stimuli in deactivated in response to stressful stimuli in BPDBPDACC dysfunction is probably a key factor in the ACC dysfunction is probably a key factor in the emotional dysregulation seen in BPD emotional dysregulation seen in BPD

--Schmahl and Herpertz, --Schmahl and Herpertz, J Psych ResJ Psych Res 41:419-427, 2006 41:419-427, 2006

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Frontolimbic Inhibitory FunctionFrontolimbic Inhibitory Function

BPD patients were asked to push a BPD patients were asked to push a button for words in standard font but button for words in standard font but not for italicized words.not for italicized words.

BPD patients were more impulsive than BPD patients were more impulsive than controls, particularly when the italicized controls, particularly when the italicized words were negative.words were negative.

In contrast to controls, BPD subjects In contrast to controls, BPD subjects showed showed amygdalar reaction and amygdalar reaction and activity in subgenual cingulate and in activity in subgenual cingulate and in medial OFC.medial OFC.

- Silbersweig et al.: - Silbersweig et al.: Am J PsychAm J Psych 164:1832-1841, 2007 164:1832-1841, 2007

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Frontolimbic Inhibitory FunctionFrontolimbic Inhibitory Function(cont.)(cont.)

Also in response to negative words, Also in response to negative words, BPD subjects showed BPD subjects showed activity in activity in the dorsal ACC.the dorsal ACC.

Hence even though they were not Hence even though they were not able to exercise impulse control, able to exercise impulse control, they were aware they had to devote they were aware they had to devote other resources to monitoring it.other resources to monitoring it.

- Silbersweig et al.: - Silbersweig et al.: Am J PsychAm J Psych 164:1832-1841, 2007 164:1832-1841, 2007

Neuroimaging data of adult BPD Neuroimaging data of adult BPD patients suggest that amygdalar patients suggest that amygdalar hypersensitivity and emotional hypersensitivity and emotional

dysregulationdysregulationmay be related to specific dysfunctionsmay be related to specific dysfunctions

in the prefrontal cortexin the prefrontal cortexand the ACC.and 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

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 13:329-344, 1999

Heightened Emotional Heightened Emotional SensitivitySensitivity

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Heightened Emotional Heightened Emotional SensitivitySensitivity (cont.) (cont.)

Morphing of facial expressions is needed to Morphing of facial expressions is needed to accurately assess the capacity of BPD accurately assess the capacity of BPD patients to respond to emotional patients to respond to emotional expressions.expressions.

Faces change gradually and monotonically Faces change gradually and monotonically from neutral to prototypical emotional from neutral to prototypical emotional expressions at maximum intensity.expressions at maximum intensity.

Allows assessment of how intense a facial Allows assessment of how intense a facial expression must be before accurately expression must be before accurately recognized.recognized.

- Lynch et al, Emotion 4:647-655, 2006

Morphed Fear Faces – Within Person

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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 4:647-655, 2006

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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 BPD—these patients overreact to relatively minor emotional expressions and interpersonal cues.

- Lynch et al, - Lynch et al, Emotion Emotion 4:647-655, 4:647-655, 20062006

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How well do BPD How well do BPD patients mentalize?patients mentalize?

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DefinitionDefinition

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).

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Reading the Mind in the Reading the Mind in the Eyes TestEyes Test

(RMET)

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Reading Faces & BPDReading 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

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Reading Faces & BPDReading 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

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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.

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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 not—they have difficulty linking trustworthiness with facial expression.

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Reading TrustworthinessReading Trustworthiness

BPD group sees faces as less BPD group sees faces as less trustworthy than controlstrustworthy than controlsIn contrast to trust, BPDs and In contrast to trust, BPDs and controls read fear similarlycontrols read fear similarlyBPD group takes longer to judge BPD group takes longer to judge faces as more trustworthy: also, faces as more trustworthy: also, shows more decision uncertaintyshows more decision uncertainty

- Fertuck 2009

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Paradox in the BPD FieldParadox in the BPD Field

The so-called “radar” for the The so-called “radar” for the therapist’s countertransference therapist’s countertransference reflects the BPD patients’ reflects the BPD patients’ heightened capacity to read early heightened capacity to read early changes in facial expressions.changes in facial expressions.

However, co-existing with this However, co-existing with this capacity are misinterpretations that capacity are misinterpretations that are quasi-delusional.are quasi-delusional.

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Donegan Subjects on Neutral Donegan Subjects on Neutral FacesFaces

“They look like mug shots, like someone who just got arrested”

“They look fake, like a façade—they’re hiding something”

“They look like they are plotting something—untrustworthy”

- Donegan, Biological Psychiatry, 2003

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Paradox in the BPD FieldParadox in the BPD Field (cont.)

Heightened sensitivity may be both Heightened sensitivity may be both accurate and inaccurate.accurate and inaccurate.

Accuracy probably varies depending Accuracy probably varies depending on the state of the attachment on the state of the attachment relationship, the presence of relationship, the presence of powerful feelings, and the degree of powerful feelings, and the degree of ambiguity of the facial expression.ambiguity of the facial expression.

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Paradox in the BPD FieldParadox 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

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Clinical ImplicationsClinical Implications

Clinician needs to be aware that the patient Clinician needs to be aware that the patient may be accurately tuning in to a not-yet-may be accurately tuning in to a not-yet-conscious feeling state in the therapist.conscious feeling state in the therapist.

Clinicians must remember that neutral faces Clinicians must remember that neutral faces represent the most ambiguous threat.represent the most ambiguous threat.

It is also possible that the patient may be It is also possible that the patient may be misinterpreting and overreacting to a small misinterpreting and overreacting to a small change in facial expression.change in facial expression.

Therapists must be aware of nonverbal Therapists must be aware of nonverbal communications to patients.communications to patients.

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Emotion RecognitionEmotion Recognition

BPD subjects have a bias BPD subjects have a bias towards the perception of anger, towards the perception of anger, rejection, or social threat.rejection, or social threat.

They see the world and others They see the world and others as dangerous, and themselves as dangerous, and themselves as powerless and unacceptable.as powerless and unacceptable.

- Domes et al, J Personality Disorders 23:6-19, 2009

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Emotion RecognitionEmotion Recognition (cont.) (cont.)

Intact neurocircuitry within the Intact neurocircuitry within the amygdala is essential for intact amygdala is essential for intact emotion recognition.emotion recognition.

Patients with lesions of the amygdaloid Patients with lesions of the amygdaloid complex show impaired recognition of complex show impaired recognition of negative facial expressions.negative facial expressions.

- Adolphs et al, Nature 433:68-72, 2005 - Domes et al, J Personality Disorders 23:6-19, 2009

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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 frontolimbic network, in particular reduced amygdalar volume and enhanced amygdalar responding to emotional stimuli.

Domes et al, J Pers Diorders 23:6-19,2009

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Emotional arousal interferes with Emotional arousal interferes with social or cognitive processing and social or cognitive processing and might contribute to the characteristic might contribute to the characteristic alterations in facial emotion alterations in facial emotion recognition.recognition.

Maternal and romantic love activate Maternal and romantic love activate an attachment system that may an attachment system that may deactivate rational processing of deactivate rational processing of feelings and perceptions of others.feelings and perceptions of others.


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Indications of Attachment Indications of Attachment Hyperactivity in Core Symptoms Hyperactivity in Core Symptoms

of BPDof BPD

Pattern of unstable and intense Pattern of unstable and intense interpersonal relationshipsinterpersonal relationships

Frantic efforts to avoid abandonmentFrantic efforts to avoid abandonment

Rapidly escalating tempo, moving from Rapidly escalating tempo, moving from acquaintance to great intimacyacquaintance to great intimacy


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Pre-Mentalizing Modes of Pre-Mentalizing Modes of Subjectivity in BPD: Psychic Subjectivity in BPD: Psychic

Equivalence ModeEquivalence Mode

Mind-world isomorphismMind-world isomorphism

Mental reality = external realityMental reality = external reality

Intolerance of alternative perspectivesIntolerance of alternative perspectives—reality is how I see things.—reality is how I see things.

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Pre-Mentalizing Modes of Pre-Mentalizing Modes of Subjectivity in BPD: Psychic Subjectivity in BPD: Psychic

EquivalenceEquivalence (cont.)(cont.)

Perceived loss of attachment figurePerceived loss of attachment figure

failure of mentalizing failure of mentalizing

psychic equivalence psychic equivalence

intensification of unbearable affect intensification of unbearable affect

self-harm or suicide attemptself-harm or suicide attempt

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Attachment & MentalizingAttachment & 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

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The presence of a social companion buffers the HPA response to stress.

(Mat. Sep. monkeys lack this buffering effect-not shown here)

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Animals with Early Adverse Experience cannotuse “social support” to buffer their stress

responses

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What isWhat is

Mentalization-Based Mentalization-Based Therapy?Therapy?

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An empirically validated therapy for MBTAn empirically validated therapy for MBT

8 year f/u study shows that it decreases 8 year f/u study shows that it decreases need for inpatient stay, reduces need for inpatient stay, reduces suicidality, improves BPD symptoms and suicidality, improves BPD symptoms and maintains gains compared to controls.maintains gains compared to controls.

-Bateman and Fonagy 1999,2001,2008

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Mentalization-Based Mentalization-Based TherapyTherapy

Designed to stimulate the attachment system while helping patient maintain mentalizing

Primary focus is on patient’s current mental state

De-emphasizes deep unconscious concerns

Recovery of mentalizing is more important than insight

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Mentalization-Based Mentalization-Based TherapyTherapy (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 patient’s mind rather than behavior

Relate to current event or activity

Use of therapist’s mind as model

Active engagement with the patient

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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

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Therapist helps the patient generate multiple perspectives

Therapist constructs an image of the patient

Patient’s attention is focused on the therapist’s experience when it offers an opportunity to clarify misunderstandings

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HOW DOESHOW DOES

E M P A T H YE M P A T H YDIFFER FROMDIFFER FROM

MENTALIZATION?MENTALIZATION?

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Empathy vs. MentalizingEmpathy vs. Mentalizing

Empathy has three components:Empathy has three components:

An affective reaction that involves sharing An affective reaction that involves sharing of another person’s emotional stateof another person’s emotional state

A cognitive capacity to imagine other A cognitive capacity to imagine other people’s perspectivespeople’s perspectives

A stable ability to maintain a self-other A stable ability to maintain a self-other distinctiondistinction

- Choi-Kain & Gunderson, Am J Psychiatry

165:1127-1135, 2008

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Empathy vs. MentalizingEmpathy vs. Mentalizing

Both involve appreciation of mental states in Both involve appreciation of mental states in othersothers

Empathy adds the dimensions of sharing in Empathy adds the dimensions of sharing in those mental states and having empathic those mental states and having empathic concern for othersconcern for others

Empathy is more other-oriented while Empathy is more other-oriented while mentalization is equally self- and other-orientedmentalization is equally self- and other-oriented

Empathy involves cognitive skill and experience Empathy involves cognitive skill and experience of affect, but its content is primarily affectively of affect, but its content is primarily affectively focusedfocused

- Choi-Kain & Gunderson, Am J Psychiatry

165:1127-1135, 2008

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Implicit MentalizationImplicit Mentalization

Unconscious, automatic, or Unconscious, automatic, or procedural operations of an procedural operations of an individual’s ability to imagine his individual’s ability to imagine his own and others’ mental statesown and others’ mental states

Taking turns in conversationTaking turns in conversation

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Explicit MentalizationExplicit Mentalization

Deliberately makes conscious Deliberately makes conscious efforts to know one’s own and efforts to know one’s own and others’ internal experiencesothers’ internal experiences

A therapist actively and consciously A therapist actively and consciously works to imagine the mental states works to imagine the mental states of the patient and encourages the of the patient and encourages the patient to do the samepatient to do the same

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Reflective functioning and Reflective functioning and BPDBPD

Reflective functioning (RF) is predictive Reflective functioning (RF) is predictive of BPD diagnosis only in subjects with of BPD diagnosis only in subjects with history of abusehistory of abuse

Because RF varies depending on Because RF varies depending on context, the assessment of context, the assessment of mentalization as a marker of BPD mentalization as a marker of BPD remains problematic.remains problematic.

- Choi-Kain & Gunderson, Am J Psychiatry 165:1127-1135, 2008

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Mirror Neurons & Mirror Neurons & MentalizationMentalization

The fundamental mechanism that allows us to The fundamental mechanism that allows us to understand the actions and emotions of others understand the actions and emotions of others involves the activation of the mirror neuron involves the activation of the mirror neuron system for actions and the activation of system for actions and the activation of viscero-motor centers for the understanding of viscero-motor centers for the understanding of affect.affect.

Action observation causes the automatic Action observation causes the automatic activation of the same neural mechanism activation of the same neural mechanism triggered by action execution or even by the triggered by action execution or even by the sound produced by the same action.sound produced by the same action.

- Gallese et al, Trends in Cognitive Science 8:396-405, 2004

- Koehler et al, Science 97:846-848, 2002

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Mirror Neurons & MentalizationMirror 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 40:655-664, 2003

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Mirror Neurons & MentalizationMirror 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 14:319-325, 2008

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CONCLUSIONSCONCLUSIONS

BPD patients are unusually BPD patients are unusually perceptive but tend to perceptive but tend to misinterpret trustworthinessmisinterpret trustworthiness

Mentalizing exists on a Mentalizing exists on a continuum and is highly variable continuum and is highly variable in BPDin BPD

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CONCLUSIONSCONCLUSIONS

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

Heightened Emotional Sensitivity and Transference in BPD

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