Thursday, September 16, 2010

Borderline Personality Disorder and Glutamate

If you recall from Love and Opium, I discussed how borderline personality disorder possibly stems from attachment problems combined with temperamental sensitivity plus opiate receptor issues.  And in other posts, I've discussed the basic idea that excess glutamate is Evil in our poor brains.

Well, a new article in the Archives of General Psychiatry brings it all together!  Amazing what happens when you pay attention.

Let's review.  Borderline Personality Disorder is a disruption of healthful coping skills, leading to impulsive behavior, inability to contain emotion properly, and difficulty controlling anger.  This disorder affects 2% of the population and 20% of psychiatric inpatients, so chances are you know someone who suffers from it.

So is this all psychological, or are there actual neurological correlates in the brain?  Yes, that is a silly question because OF COURSE there are neurological correlates in the brain.  It comes down to dysregulation in the fronto-limbic network.  The limbic region of the brain controls emotion, the frontal region is rather like the policeman in your head that tells you that your hysterical internal observations about your Aunt Gertie's Awful Hat are NOT appropriate to share at the present time and place.  So if your fronto-limbinc network is out of whack, you can be impulsive, easily angered, and too sensitive.

So the Archives, in true form, goes into excruciating detail about all the fMRI and other imaging studies that have failed to show any conclusive correlations to borderline personality disorder.  Don't worry!  I want to keep my few dozen fans!  So let's skip to the good stuff.  Fronto-limbic function in borderline personality disorder was found to be especially dysregulated with respect to remembering "unresolved negative life events."

I've no doubt Kurt Harris, M.D. knows more about these types of imaging studies, but the next thing our intrepid borderline personality disorder researchers did was get a Proton Magnetic Resonance Spectroscopy (MRS) scan of their borderline patients.  MRS apparently allows one to follow the metabolism of all sorts of interesting neurotransmitter characters, including glutamate, while the scanned subject is still alive and thinking.

Thirty female patients diagnosed with borderline personality disorder were scanned and tested alongside thirty female matched controls.  And, not surprisingly, differences were found.  Patients were higher with respect to anxiety, depression, impulsivity, and dissociation ("out of body" sorts of feelings, or numbness of response to intense emotions).  And on the brain imaging studies, borderline patients had significantly higher amounts of glutamate (the excitatory, and, in excess, neurotoxic neurotransmitter) in the anterior cingulate cortex (ACC) than the controls.  Since the ACC is the heart of our ability to contain our impulses, having too much glutamate on board could presumably short circuit our ability to restrain ourselves.

Abnormal levels of frontal glutamate have also been found in studies of depression, schizophrenia, and ADHD.  And glutamate dysregulation has also been found to be a problem with dissociation symptoms in general.  The difference is, insurance companies will pay when I record a diagnosis as major depression, schizophrenia, or ADHD (all considered "organic" disorders), whereas they might not if I made the mistake of coding a patients' primary problem as borderline personality disorder (considered "psychological" and not organic).

And men, if you  are looking for male data here, you are a bit out of luck.  Turns out all relevant MRS studies of borderline personality disorder have included only women.

Insurance companies - it is ALL organic.  Psychology is expressed within the confines of the neurochemistry of the organism.  And, eventually, all of it will have to be paid for, one way or another.

15 comments:

  1. So that must mean that men do not have borderline personalities and are in fact sane, rational, and logical. Women on the other hand... ;)

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  2. Another 2% of the population that should eat a ketogenic diet!

    http://perfecthealthdiet.com/?p=472.

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    1. Paul, why would a ketogenic diet help with bpd?

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  3. Jamie - Let's just say that when a woman says she is thirsty, she doesn't necessarily want you to get her a glass of water.

    Paul - I've been eating two brazil nuts a day, and more coconut oil and milk. Selenium and ketones! Bring it on.

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    1. Emily, how does seleniun an diet ketone help? I thought carbs were needed to help serotonin production to ease depression?

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  4. I think when a man says he's thirsty, it also ain't water he's talkin' 'bout. "Grab me another beer, wench!"

    Seriously, though, it's amazing how many people still think psychology can be dissociated from physiology. That would be like asking why a car is not working well and getting the response "well, it's either tired or there something going on in the engine or other mechanical parts." I thought we got rid of Cartesian dualism once and for all?

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  5. Aaron - I would urge caution if using that drink request approach with the women of the paleosphere. Some of them have sledgehammers named "towanda" and one certainly wouldn't want to be on the wrong end of a pink kettlebell!

    There are still some circles where biology and psychology are kept falsely separate. It is a shame, for in some respects neuroscience is the last great medical frontier. Psychology and a nutritional approach have the advantage of being able to affect the biology immediately without waiting years for a new medicine designed for some newly discovered pathway.

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  6. well one does wonder why women are disproportionately represented in the borderline category. i'm sure you have a fantastic post planned on why/how estrogen induces the excess glutamate or testosterone protects against it or something like that.
    figuring out borderline PD would really improve my life. too many suicide attempts in that crowd. makes for lots of work, mostly unsatisfying.

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  7. Dan - the hormone question is an interesting one. There are plenty of male borderline patients - it tends to present somewhat differently in men, and is more likely to be classified as narcissistic personality disorder or possibly antisocial personality disorder. The reason you don't see them in the ICU is that men also attempt suicide differently than women. Women are more likely to make attempts and use non-lethal (or less lethal) means, such as ODs and wrist-cutting. Men are more likely to die from suicide (particularly older white men), probably because men tend to use guns, jumping off bridges, and hanging as means, which are obviously much more lethal. I've seen some gruesome choices along the way, as I'm sure you have seen, many times.

    Physicians are more likely to complete suicide than the general population - women physicians in particular have higher risk, increased by as much as 130%. As physicians tend to have lower rates of obesity, diabetes, cancer, heart disease, etc. than the general population, the suicide risk stands out.

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  8. Should I stop eating protein then, because that is how we make glutamate. This all sounds silly, another baseless theory about why I am the way I am, when in reality, I dont see how anyone could be perfectly normal after being abandoned, beaten and molested for their first 20 years of life. Dont blame this on an amino acid by product. A tip; dont go to a male psychiatrist or therapist if u r a woman. They often call my escort line or hit on me at clubs. Now I wont see one for help bc I figure they are sexing me in their heads. They arent more developed than the rest of the male species. Stick with ladies:)

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    1. I'm so sorry to hear all of that happened to you. I understand that the horrible things that happened to you shaped you. I wasn't abused, but my parents were far from perfect-very narcissistic, even though they loved me in their own way. My sister turned out fine, but I have BPD. Interestingly, birth control makes me rage psychotically. When I'm off it, and even supplement with things that raise estrogen, I feel so much better. Saint John's wort and 5HTP and exercise also help a lot. Lack of sleep, alcohol, and changes in hormones definitely affect my behavior. Those supplements, hormones, and amino acids aren't responsible for the way I am, but they make it so much easier to control my anger and insecurity and mood. I am very interested to read what Emily has to say about others, like glutamate.

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    2. From my understanding, and as someone who has BPD, the therapist and/or the patient determines that your coping skills are disrupted. I've known for a long time that the things I do to cope are counter productive, and hurt me rather than help. So do two other people I know with BPD. If the anger and emotion were reasonable, then people with BPD wouldn't self-injure and engage in highly self-destructive and impulsive activities.

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  9. “Borderline Personality Disorder is a disruption of healthful coping skills, leading to impulsive behavior, inability to contain emotion properly, and difficulty controlling anger.”

    Who determines whether someone’s coping skills are disrupted, their behavior is impulsive, their emotions are not being contained properly, and their anger should be better controlled, or whether they are reacting rationally to an intolerable situation?

    “There are plenty of male borderline patients - it tends to present somewhat differently in men, and is more likely to be classified as narcissistic personality disorder or possibly antisocial personality disorder.”

    How does Borderline Personality Disorder get mistaken for Antisocial Personality Disorder, when APD involves “a pervasive pattern of disregard for, and violation of, the rights of others,” and BPD does not?

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  10. "And men, if you are looking for male data here, you are a bit out of luck. Turns out all relevant MRS studies of borderline personality disorder have included only women."

    This is so discouraging. Dealing with this issue as a male, who was raised in a deeply-religious country full of misogynistic idiosyncrasies dictating women are the only ones allowed to feel, and where bullying and alcohol are implicitly encouraged by society, has made it virtually impossible for me to achieve any level of normality.

    For example, anger seems quintessential of a BDP diagnosis, but I rarely see certain situations being explored in which most, if not all of the anger is being directed inwards, breeding frustration, self-esteem issues and depression. BDP in and of itself is extremely stigmatizing, so it is easy to imagine why seeking help it is so daunting when it is inevitable to associate the labels “criminal”, “violent”, “abusive” whenever men are the focus of the discussion. Maybe there are those that, instead of succumbing to their urges and employing violence and/or anti-social behavior, prefer to simply abandon before being abandoned. This is a very different expression of the disorder that is rarely conveyed with enough emphasis when it comes to males.

    I do not want to belittle the plight of females afflicted by BPD, but I do want to bring to light that men suffer from this disorder too. Yes, there are surveys out there already making my point, but I want to see more effort in examining the disorder more closely on males. Just by enabling more men to open up and seek help, everything else should follow.

    We've come a long way in how we deal with behavioral disorders, and it is hard for me to complain when I take step back and I see how most of humanity is suffering in one way or another. Even so, we can never discard context as a main variable, and for men like myself, that context is what sometimes makes life almost unbearable.

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  11. So, nutritionally, how do you address it? (BPD) (lowering glutamate..?)

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