Self-harm, Pain, and the Brain

In discussing personality disorders, I’d like to build on earlier post by a classmate, Jaime Biava. He discussed the idea that individuals diagnosed with Borderline Personality Disorder (BPD) may show changes in the HPA axis area of the brain. A person diagnosed with BPD may manifest outward behaviors such as cutting, suicidal gestures, bulimia, and substance abuse. Commonly, BPD is found in people who suffered maltreatment and neglect in childhood (Cohen, et al, 2006), or long-term exposure to stress (Leichsenring, et al, 2011). Yet, BPD is a relatively new diagnosis in psychiatry; in the past, persons fitting the criteria were often diagnosed with ‘pseudo-neurotic schizophrenia’, or ‘hysteria’, prior to the disorder being studied and subsequently classified by Otto Kernberg in the 1960s (Friedel, 2004; Kernberg, 1967). Indeed, there are even psychiatric professionals today who do not believe that Borderline Personality Disorder exists. Thus, more recent findings of actual changes in the brain that are unique to persons with BPD not only add weight to the validity of the diagnosis, but also may assist professionals and the public to become more accepting of  the true suffering that people with Borderline Personality Disorder  endure.

To review, Borderline Personality Disorder is found in approximately 1-5% of all persons (Leichsenring, et al, 2011). Currently the most effective therapies- mentalization therapy or dialectical behavior therapy– assist with repair of coping mechanisms disrupted by trauma. When a child’s brain is repeatedly exposed to stress or trauma, their psychological and emotional development may be forestalled or maladapted (O’Neill & Frodl, 2012). For many years, it seemed as if most of the research about BPD focused on these psycho-social factors. Along the same lines, the thinking on drug and alcohol addiction used to be that individuals were psychologically immature or weak, and this was why they used substances (Khantzian, 1985). The germ of truth in such thinking is that a dearth of coping skills coupled with unmet emotional needs does seem to strengthen the grip of addiction, or addictive behavior (Farber, 1997). Repetitive self-harming behavior (such as cutting, bulimia or substance abuse) in persons with BPD may be conceptualized as addictive because the goal of the behavior not only serves powerful emotional needs, but also may be produced by changes in the brain.

Over the last fifteen years a number of studies have shown that there is a reduction in the volume of both the hippocampus and the amygdala in persons with Borderline Personality Disorder, although these changes appear to be most common in persons who are diagnosed with both Post Traumatic Stress Disorder (PTSD) and BPD (Leichsenring, et al, 2011). Moreover, studies using brain imaging have shown that the amygdala and frontal area of the brain (called the medial prefrontal cortex, or MPFC) were excessively stimulated in persons with BPD (Koenigsberg, et al, 2009; Silbersweig, et al, 2007). Occupational therapists using neuro-imaging have found that the MPFC, which is also used to process pain sensations, is impaired in children with autism, and have theorized that persons with BPD who self-injure are perhaps using a form of self-stimulation (as children with autism do) in a misguided attempt to regulate their emotions (Brown, Shankar, & Smith, 2009). Another possibility is that part of the difficulty people with BPD have with self-regulation has to do with a sensory processing disorder (Brown, et al, 2009).

Finding structural and chemical differences in the brains of persons with BPD helps to refute the notion that self-harming behavior is willful or something that can be controlled by ‘mind over matter’.  There is a fair amount of research that speaks to the idea of self-harm in people suffering from Borderline Personality Disorder as being a method to self-medicate (Farber, 1988; Brown, et al, 2009).  The original hypothesis of self-medication for emotional pain came from Khantzian (1985), who in studying addiction concluded that persons abusing drugs seek to medicate painful emotional states, and that the inability to regulate those moods is often rooted in a stressful or abusive childhood history. Thus, when a person burns or cuts their arm, that sensation is preferable to enduring the emotional pain they are experiencing. The concept of palliating emotional pain by cutting can be difficult to accept when viewing someone whose arm is so scarred that it

appearspic as if an ace bandage has been wrapped around it.

Those who participate in repetitive self-harming behavior have offered another explanation: that they attempt to numb emotional pain by cutting/burning themselves (Farber,1985), almost as a means of potent distraction. Yet the relationship between pain and the BPD diagnosis may be more complex. A recent study asked test subjects to immerse their hand in frigid water; the longer subjects were able to withstand the frozen water determined the level of pain tolerance. These results revealed that individuals with BPD had a much higher pain tolerance than people with no mental health condition, or even than persons diagnosed with major depression (Pavony, & Lenzenweger, 2013). It remains to be seen how having a high pain tolerance would play a part in compelling repetitive self-harming behavior. At the present time, we only know that regardless of why self-harming behavior happens, therapy does assist individuals in gaining insight and learning less destructive coping methods; hardly a panacea, but offering hope to those who struggle with Borderline Personality Disorder.

References

Brown, S., Shankar, R., & Smith, K. (2009). Borderline personality disorder and sensory processing impairment. Progress in Neurology and Psychiatry, 13, 4, 10-16.

Cohen, R. A., Grieve, S., Hoth, K. F., Paul, R. H., Sweet, L., Tate, D., Gunstad, J., … Williams, L. M. (2006). Early Life Stress and Morphometry of the Adult Anterior Cingulate Cortex and Caudate Nuclei. Biological Psychiatry, 59, 10, 975-982.

Farber, S. K. (1998). Self-Medication, Traumatic Reenactment, and Somatic Expression in Bulimic and Self-Mutilating Behavior. Clinical Social Work Journal, 25, 1, 87-106.

Friedel, R. O. (2004). Borderline personality disorder demystified: An essential guide for understanding and living with BPD. New York: Marlowe & Co.

Kernberg OF (1967): Borderline personality organization. J Am Psychoanal Assoc 15:641–685.

Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. The American Journal of Psychiatry, 142, 11, 1259-64.

Koenigsberg, H. W., Fan, J., Ochsner, K. N., Liu, X., Guise, K. G., Pizzarello, S., Dorantes, C., … Siever, L. J. (2009). Neural correlates of the use of psychological distancing to regulate responses to negative social cues: a study of patients with borderline personality disorder. Biological Psychiatry, 66, 9, 854-63.

Leichsenring, F., Leibing, E., Kruse, J., New, A. S., & Leweke, F. ( 2011). Borderline personality disorder. The Lancet, 377, 9759, 74-84.

O’Neill, A., & Frodl, T. (2012). Brain structure and function in borderline personality disorder. Brain Structure & Function, 217, 4, 767-82.

Pavony, M. T., & Lenzenweger, M. F. (2013). Somatosensory Processing and Borderline Personality Disorder: Pain Perception and a Signal Detection Analysis of Proprioception and Exteroceptive Sensitivity. Personality Disorders: Theory, Research, and Treatment.

Silbersweig, D., Clarkin, J. F., Goldstein, M., Kernberg, O. F., Tuescher, O., Levy, K. N., Brendel, G., … Stern, E. (January 01, 2007). Failure of frontolimbic inhibitory function in the context of negative emotion in borderline personality disorder. The American Journal of Psychiatry, 164, 12, 1832-41.

 

2 thoughts on “Self-harm, Pain, and the Brain

  1. Interesting points, Lisa.

    I’m particularly intrigued by the fact that some psychiatric providers “don’t believe” in BPD. I have heard this before, and am glad you bring it up. Breaking it down, a diagnosis is a description (often a list) of symptoms. Used to communicate among clinicians and allied professionals, agencies, insurance companies, they can be quite helpful. (Please forgive my gross over-simplification, as I try to approach this from the ground up.) If BPD is an adequate descriptor of the individual’s behaviors — and given that BPD treatment protocols work well for people who meet the diagnostic criteria — I wonder, what these providers would like instead of “BPD”? I’m sure there are as many answers to this question as there are clinicians, and I’m not saying any of them are wrong. I’d really like to hear more.

    Of course, the stigma of psychiatric diagnoses is immense and extraordinarily pervasive in our society, and the repercussions of diagnoses go well beyond office/hospital walls. Perhaps that is what drives much of the debate. Here’s a thought-provoking webpage by patients who have received a diagnosis of BPD, and what it’s meant to them: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015320/

    Thanks for the post!

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