BPD and the broader landscape of neuropsychiatric illness

Dr. Henry A. Nasrallah’s recent Editorial on borderline personality disorder (BPD) (Current Psychiatry, From the Editor, April 2014, p. 19-20, 32 [http://bit.ly/1e8yAwE]) describes BPD as a heritable brain disease. I have been arguing this point for many years, often finding support from my colleague, Hagop Akiskal, MD, and opposition from my psychoanalytic colleagues.

In recent papers^1,2 on brain changes in BPD and the connection between BPD and bipolar disorders, I wrote that there often is a heritable aspect to the condition. There are exceptions to such heritability, as in the setting of a horrific environment (eg, father-daughter incest, parental brutality), where the same symptoms seen in BPD develop primarily from post-natal influences. Dr. Akiskal and I were discussing this a long time back, before MRI. Now I feel vindicated, with generous help from someone of Dr. Nasrallah’s prestige and influence.

There also is electrophysiological (including evoked potential) evi­dence for neural pathology in BPD, as well as data derived from single photon emission CT scanning. The burgeoning literature on MRI and functional MRI studies of BPD is in good agreement about the brain changes most relevant to BPD and that are found with regularity in this condition.

Particularly when BPD is diag­nosed in people (usually women) who do not have a history of neglect, sexual molestation, parental humili­ation or cruelty, or head injury, what else is there, if not genetically pre­disposed alterations in the fronto­limbic structures (and maybe the periaqueductal gray) that underlie the so-called “personality disorder,” and, not surprisingly, bipolar dis­orders, especially bipolar II disor­der, which often is the other side of the coin as BPD, and amenable to the same combination of medication and psychotherapy?

Michael H. Stone, MD
Professor of Clinical Psychiatry Columbia College of Physicians and Surgeons
New York, New York

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As a psychiatrist/psychoanalyst who works with BPD patients, I read Dr. Nasrallah’s April 2014 Editorial with great interest and enthusiasm. Over the past 10 years, I have been impressed with the number of patients with BPD whose nonverbal learning disorders and auditory and visual pro­cessing disorders have gone undiag­nosed. Recently, I lectured on this topic to the staff of a school for children with a range of neuropsychiatric disorders; the staff found my observations about such comorbidity consistent with their observations. These dysfunctions, or neurological variations—unknown to the parent and the child—interfere with early object-relation formation, attachment capacity, and learning. Neuropsychiatry and psychological development are, in fact, part of the same system.

An example: For 12 years, I have been treating a patient who has audi­tory processing and working memory problems, meaning that she could not process the connections among different ideas. This difficulty frus­trated her parents, who, in their frus­tration, criticized her for not paying attention. She was labeled “bad” and assumed the role of the “black sheep” in her family. Although she was intelligent, she was often wrong in her judgments and choices, and easily frustrated. In therapy, as I realized what part of her prob­lem was, I changed my technique.

When my patient asked me to tell her the sequence of understandings that we had just put together, I invited her to take my pad and write down her sense of it. As she described each part of that sequence to me, we would discuss it and I would remind her of lost fragments. Gradually, she learned to put ideas together; however, I also watched her struggle to hold these ideas in working memory and to use them.

Over time, she has improved and is more functional. After several years of dis­ability, she returned to work, although she still struggles interpersonally.

With many of such patients, I have had to modify traditional techniques of psy­chotherapy. I am fascinated by, and enjoy, such intensive psychotherapy. I am also amazed to see the impact of previously unknown neuropathologic variations on development. The more I learn about the impact of neuropsychiatry on psychologi­cal development, the more I can help my patients.

Howard Wishnie, MD
Cambridge, Massachusetts

Dr. Nasrallah responds
I appreciate Dr. Stone’s kind words and concur­rence with my thinking about BPD. It would have been appropriate to include discussion of neuro­physiological findings in my Editorial, but I opted to use my limited space to focus on structural and functional neuroimaging and genetics.

Henry A. Nasrallah, MD
Professor and Chairman Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri

Dr. Henry A. Nasrallah’s recent Editorial on borderline personality disorder (BPD) (Current Psychiatry, From the Editor, April 2014, p. 19-20, 32 [http://bit.ly/1e8yAwE]) describes BPD as a heritable brain disease. I have been arguing this point for many years, often finding support from my colleague, Hagop Akiskal, MD, and opposition from my psychoanalytic colleagues.

In recent papers^1,2 on brain changes in BPD and the connection between BPD and bipolar disorders, I wrote that there often is a heritable aspect to the condition. There are exceptions to such heritability, as in the setting of a horrific environment (eg, father-daughter incest, parental brutality), where the same symptoms seen in BPD develop primarily from post-natal influences. Dr. Akiskal and I were discussing this a long time back, before MRI. Now I feel vindicated, with generous help from someone of Dr. Nasrallah’s prestige and influence.

There also is electrophysiological (including evoked potential) evi­dence for neural pathology in BPD, as well as data derived from single photon emission CT scanning. The burgeoning literature on MRI and functional MRI studies of BPD is in good agreement about the brain changes most relevant to BPD and that are found with regularity in this condition.

Particularly when BPD is diag­nosed in people (usually women) who do not have a history of neglect, sexual molestation, parental humili­ation or cruelty, or head injury, what else is there, if not genetically pre­disposed alterations in the fronto­limbic structures (and maybe the periaqueductal gray) that underlie the so-called “personality disorder,” and, not surprisingly, bipolar dis­orders, especially bipolar II disor­der, which often is the other side of the coin as BPD, and amenable to the same combination of medication and psychotherapy?

Michael H. Stone, MD
Professor of Clinical Psychiatry Columbia College of Physicians and Surgeons
New York, New York

----------------------------------------------------------------------------------------------------------

As a psychiatrist/psychoanalyst who works with BPD patients, I read Dr. Nasrallah’s April 2014 Editorial with great interest and enthusiasm. Over the past 10 years, I have been impressed with the number of patients with BPD whose nonverbal learning disorders and auditory and visual pro­cessing disorders have gone undiag­nosed. Recently, I lectured on this topic to the staff of a school for children with a range of neuropsychiatric disorders; the staff found my observations about such comorbidity consistent with their observations. These dysfunctions, or neurological variations—unknown to the parent and the child—interfere with early object-relation formation, attachment capacity, and learning. Neuropsychiatry and psychological development are, in fact, part of the same system.

An example: For 12 years, I have been treating a patient who has audi­tory processing and working memory problems, meaning that she could not process the connections among different ideas. This difficulty frus­trated her parents, who, in their frus­tration, criticized her for not paying attention. She was labeled “bad” and assumed the role of the “black sheep” in her family. Although she was intelligent, she was often wrong in her judgments and choices, and easily frustrated. In therapy, as I realized what part of her prob­lem was, I changed my technique.

When my patient asked me to tell her the sequence of understandings that we had just put together, I invited her to take my pad and write down her sense of it. As she described each part of that sequence to me, we would discuss it and I would remind her of lost fragments. Gradually, she learned to put ideas together; however, I also watched her struggle to hold these ideas in working memory and to use them.

Over time, she has improved and is more functional. After several years of dis­ability, she returned to work, although she still struggles interpersonally.

With many of such patients, I have had to modify traditional techniques of psy­chotherapy. I am fascinated by, and enjoy, such intensive psychotherapy. I am also amazed to see the impact of previously unknown neuropathologic variations on development. The more I learn about the impact of neuropsychiatry on psychologi­cal development, the more I can help my patients.

Howard Wishnie, MD
Cambridge, Massachusetts

Dr. Nasrallah responds
I appreciate Dr. Stone’s kind words and concur­rence with my thinking about BPD. It would have been appropriate to include discussion of neuro­physiological findings in my Editorial, but I opted to use my limited space to focus on structural and functional neuroimaging and genetics.

Henry A. Nasrallah, MD
Professor and Chairman Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri

Dr. Henry A. Nasrallah’s recent Editorial on borderline personality disorder (BPD) (Current Psychiatry, From the Editor, April 2014, p. 19-20, 32 [http://bit.ly/1e8yAwE]) describes BPD as a heritable brain disease. I have been arguing this point for many years, often finding support from my colleague, Hagop Akiskal, MD, and opposition from my psychoanalytic colleagues.

In recent papers^1,2 on brain changes in BPD and the connection between BPD and bipolar disorders, I wrote that there often is a heritable aspect to the condition. There are exceptions to such heritability, as in the setting of a horrific environment (eg, father-daughter incest, parental brutality), where the same symptoms seen in BPD develop primarily from post-natal influences. Dr. Akiskal and I were discussing this a long time back, before MRI. Now I feel vindicated, with generous help from someone of Dr. Nasrallah’s prestige and influence.

There also is electrophysiological (including evoked potential) evi­dence for neural pathology in BPD, as well as data derived from single photon emission CT scanning. The burgeoning literature on MRI and functional MRI studies of BPD is in good agreement about the brain changes most relevant to BPD and that are found with regularity in this condition.

Particularly when BPD is diag­nosed in people (usually women) who do not have a history of neglect, sexual molestation, parental humili­ation or cruelty, or head injury, what else is there, if not genetically pre­disposed alterations in the fronto­limbic structures (and maybe the periaqueductal gray) that underlie the so-called “personality disorder,” and, not surprisingly, bipolar dis­orders, especially bipolar II disor­der, which often is the other side of the coin as BPD, and amenable to the same combination of medication and psychotherapy?

Michael H. Stone, MD
Professor of Clinical Psychiatry Columbia College of Physicians and Surgeons
New York, New York

----------------------------------------------------------------------------------------------------------

As a psychiatrist/psychoanalyst who works with BPD patients, I read Dr. Nasrallah’s April 2014 Editorial with great interest and enthusiasm. Over the past 10 years, I have been impressed with the number of patients with BPD whose nonverbal learning disorders and auditory and visual pro­cessing disorders have gone undiag­nosed. Recently, I lectured on this topic to the staff of a school for children with a range of neuropsychiatric disorders; the staff found my observations about such comorbidity consistent with their observations. These dysfunctions, or neurological variations—unknown to the parent and the child—interfere with early object-relation formation, attachment capacity, and learning. Neuropsychiatry and psychological development are, in fact, part of the same system.

An example: For 12 years, I have been treating a patient who has audi­tory processing and working memory problems, meaning that she could not process the connections among different ideas. This difficulty frus­trated her parents, who, in their frus­tration, criticized her for not paying attention. She was labeled “bad” and assumed the role of the “black sheep” in her family. Although she was intelligent, she was often wrong in her judgments and choices, and easily frustrated. In therapy, as I realized what part of her prob­lem was, I changed my technique.

When my patient asked me to tell her the sequence of understandings that we had just put together, I invited her to take my pad and write down her sense of it. As she described each part of that sequence to me, we would discuss it and I would remind her of lost fragments. Gradually, she learned to put ideas together; however, I also watched her struggle to hold these ideas in working memory and to use them.

Over time, she has improved and is more functional. After several years of dis­ability, she returned to work, although she still struggles interpersonally.

With many of such patients, I have had to modify traditional techniques of psy­chotherapy. I am fascinated by, and enjoy, such intensive psychotherapy. I am also amazed to see the impact of previously unknown neuropathologic variations on development. The more I learn about the impact of neuropsychiatry on psychologi­cal development, the more I can help my patients.

Howard Wishnie, MD
Cambridge, Massachusetts

Dr. Nasrallah responds
I appreciate Dr. Stone’s kind words and concur­rence with my thinking about BPD. It would have been appropriate to include discussion of neuro­physiological findings in my Editorial, but I opted to use my limited space to focus on structural and functional neuroimaging and genetics.

Henry A. Nasrallah, MD
Professor and Chairman Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri