How does BPD change the brain
Quiet after the continuous alarmHow borderline can be healed
"Then there was a tiny detail that someone said or did. And that could turn into very great, inner despair in minutes."
"Well, borderline is a horror that nobody can imagine. And there, if I don't have to, I don't want to have to dive into this lake. And I know that my sister spends her life there. And that's terrible."
"As a clinician you always had the perspective that personality disorders are more or less stable. We have the model of the ship that has an anchor chain of different lengths and the only thing we can do is somehow to get it a little further from the anchor And the change in perspective is that we are even concerned with the question, does this remission exist and how can we achieve it. "
"In the summer of 2006 I actually noticed myself that something was going wrong here."
There is Mila 26, a petite woman with long red-blonde hair. What she suffers most from are men, always men. In rows, indiscriminately. For a short time that one is everything in your life, every time it is the very big love. She is looking for closeness that she actually cannot stand. After a few weeks, at the latest after a few months, it's all over again.
"There were always situations where I was totally tense and angry and said, leave me alone, I don't want to talk. And he took that seriously and said, okay, I'll leave you alone. And then sat there "Totally desperate, how can you leave me so alone, in such a state. It's just the ambivalence in me. The other one doesn't even know where the front and back are because within two minutes I say," Get out of here, but please don't go ', and ... very bad. "
"Tension, highest tension"
Every time a man leaves her apartment, even if it is just to go home or to work, she experiences this extreme sense of abandonment. Mila remembers the acquaintance from Ulm, a weekend affair, who said goodbye to her with the words, "Let's stay friends".
"That is tension, the greatest tension, when I no longer know what I am doing…. So there is something compulsive, something driven. It has nothing to do with rational considerations, I could try again, and if not, then drive I'll go again. I have to convince him now, otherwise I won't survive this. "
Terrified, Mila drives after him, 600 kilometers to Ulm, without even thinking for a moment. Then she stands in front of his house that night, but he doesn't open - fortunately, she says today. When Mila can think again, she realizes that her behavior is not healthy. Her suspicions are confirmed in psychiatry: she suffers from a borderline personality disorder.
A disruption of control or the filtering of emotions
"It's an emotion regulation disorder." So a disruption of control or the filtering of emotions. "The fact is that with a smaller trigger there is a stronger emotion that subsides more slowly, but can also turn back into another emotion more quickly. So, strongly pronounced negative emotions, but also positive emotions that are more pronounced than in healthy people triggered faster than in healthy people, "explains Stefan Röpke, psychiatrist at the Berlin Charité.
"The second part of the disease is that most triggers are social situations. Patients are likely to have difficulty understanding at certain moments what others are thinking, what intentions are being felt by others."
The sudden, violent feelings of borderliners can even be measured. In the past ten years, brain research has been able to use imaging to make typical abnormalities in the brain visible.
"We found out through neurobiological studies that patients intersect in order to briefly activate the suppressed connectivity between the prefrontal areas and the limbic system. It's like having a very strong motor and very weak brakes."
Pain to curb feelings
Martin Bohus works at the Central Institute for Mental Health Mannheim. The "very powerful motor" - that is the limbic system, which includes the amygdala and hippocampus. Feelings like fear arise here. Borderliners show a particularly high level of activation in the limbic system, but a particularly weak level in the prefrontal cortex, which is supposed to control and slow down the strong feelings. Up to the high-speed amygdala in constant alarm condition, the weak brakes hardly penetrate unless the brakes are aggravated by pain. Injuries that borderliners often inflict on themselves have exactly this function.
In other regions, too, the brains of borderliners seem to react differently than that of healthy people. The images from the brain are not yet sufficient to reliably diagnose a borderline disorder. But they help to understand them better. They also provide evidence that the altered brain functions can return to normal.
Therapy seemed to be of little use
"Of course, this has an influence on psychotherapy, but above all on attitudes towards the patient, towards the parents, in the therapeutic community as a whole. Until neuropsychology began to assert itself, it was a psychodynamic construct that assumed that it was somehow a strange kind of developmental delay with problems in subject-object differentiation and similar constructs that are exciting to read, but have no solid evidence. And now that you know there are neurobiological correlates, you actually start which actually understand more profoundly. "
A better understanding ultimately also means better treatment options, especially with borderlines. For a long time psychology assumed a fundamental disorder of the personality, deeply anchored in the person, with little chance of a cure. Therapy seemed to be of little use beyond simple crisis management.
"The sign that the time had come was that I answered and she said," Hello "(in a tearful voice). And then I knew we were going to therapy."
Doreen is Mila's younger sister. For the past ten years she has accompanied Mila through the illness. There were times when the two of them talked on the phone for hours almost every other evening. Doreen experienced how Mila worked well in her job as an IT consultant and earned a lot of money in the process. But then she kept breaking out and doing things, as if driven by an obsession, that she then regretted.
"It used to be that whenever I lost track of my account, or worse, when the thought was there, oh, that doesn't look good at the moment, the more I spent. The more I felt there is nothing left, the more I threw it out. "
Many symptoms as with other personality disorders
"And the next week I got the call, I can't pay the rent. And of course you always feel like a money machine. The day came when I said you weren't getting the money. And then you realize how she becomes aggressive and needs the money now. It's like a drug addict who sees nothing more than that he needs the money now. Because something has already been haunted in her head that she didn't want to tell me about. "
Many symptoms of borderline are also found in other personality disorders. It is therefore often difficult to differentiate between the various disorders. In addition, many borderliners also suffer from depression, anxiety disorders or drug addiction. There is currently a controversial discussion about which criteria for borderline should be included in the classification system for diseases of the World Health Organization, ICD. The DSM manual of the American Psychiatric Association, which is also used internationally, currently names nine symptoms:
- the fear of being abandoned
- unstable relationships with others
- an unstable self-image
An estimated 2.5% of the population is affected. The proportion is highest among 15-year-olds.
- self-harming behavior related to spending, sexuality, drugs, or eating
- repeated suicidal attempts and self-harm
- quick change of mood
The number of those affected may even increase: Child and adolescent psychiatrists report more and more self-harm in their patients.
- a chronic feeling of emptiness
- violent fits of anger
- dissociative states, i.e. the feeling of not being yourself
Most people know individual symptoms of themselves. But only when they exceed a critical threshold and at least five characteristics come together, this is considered a disease. The transitions are fluid.
At the Mannheim Central Institute for Mental Health, a woman lies in the magnetic resonance tomograph, which records her brain activities. Just around the corner, in an adjoining building, another tube with a second test person. Both women are connected to one another via a video image - they can see each other, but not hear. Together they should accomplish a simple task. Whenever the experimenter plays a signal on a woman on one of the four sides of the screen, she has to tell by eye movement where she sees the signal. The task is accomplished when the other player understands and turns her gaze in the same direction.
"That's something that babies already learn. When they look at their mother and she looks elsewhere, babies follow this look. That's why we believe this is one of the very, very early, very, very basic forms of social interaction. But Nevertheless, it is very important so that we have a feeling that we are currently sharing our environment because we are looking at the same object together. "
Brain functions seem to normalize
The psychologist Peter Kirsch and his team follow what is happening in the brains of the two women. The same pattern emerges over and over again: a high level of activity in the tempo-parietal transition, a region in which movement and intentions are processed. In healthy women, the images from the two scanners largely agree both in terms of time and intensity. Kirsch speaks of a coupling of the brains at this moment. The pictures fit together like in a memory game.
"And with borderline patients, at least with acute borderline patients, the coupling is no greater than if there had been no interaction at all. So, we simply see no coupling, so to speak. This is probably one of the neural bases for the disturbed relationship between borderliners to other people. "
The neuroscientists are surprised when they involve former patients in the experiment. In everyday life they hardly suffer from the typical borderline symptoms. In fact, their brain scans also resemble those of healthy test subjects. Your brain functions seem to have normalized in this area.
A group of researchers at Heidelberg University also observed exciting things. Here, the brain waves of borderline patients were measured with the EEG while they processed visual stimuli. The experimental setup was relatively simple. The subjects were shown faces on a computer screen that showed joy or anger or both.
"They have two buttons on the computer, I think it's the arrow keys. They put their fingers on them and just have to say, this face seems angry to me or this face seems happy to me and just press a key for angry or one for There is no right or wrong, but, in my opinion, that's annoying and that's happy, "explains neuropsychologist Katja Bertsch.
The experiment shows how strong the negative expectations borderliners have towards other people. Far more often than healthy volunteers, they noticed anger on their faces. Even with a clear smile, ten percent of the borderliners pressed the "angry" button.
Visual stimulus puts borderliners on alert
When it comes to EEG measurements, Bertsch and her colleagues are primarily interested in three points in time: The first rash after around 100 milliseconds in the visual cortex - the brain registers an initial visual stimulus here: "There is something". 70 milliseconds later, the brain begins to grasp the structures of a face. After about 300 milliseconds, the face is classified: Who does it belong to, what feelings does it show?
In the experiment, the EEG was particularly high after 100 milliseconds, i.e. in the early processing phase. The visual stimulus alone apparently puts borderliners on the alert. In the later processing, however, their brain waves turned out to be weaker than in the healthy control group - borderliners need more time to evaluate the faces and make mistakes more often.
"Our assumption is that this first increased activation in the visual areas blocks this further processing or is worse possible. So when you introduce yourself when you are totally afraid and you are totally on alert and everything is really bad . Can I actually still perceive everything around me in detail? No, I'm so focused on what is frightening, or on myself, that I can no longer perceive the details. And I could imagine something very similar here happens."
Hypersensitivity seems to have subsided
Like the Mannheim researchers, the Heidelberg researchers repeated the experiment for the first time with former patients who had recovered to such an extent that they were no longer medically considered to be borderliners. They were also shown pictures while their brain waves were being measured. Particularly exciting: In the very early reaction after 100 milliseconds, they no longer differed from healthy test subjects. The hypersensitivity to possible threats seemed to have subsided. The later visual processing had also improved, but not as much.
"The good thing is actually that these early processes are remitting. Because that's something very fast and automatic."
Apparently, the therapy can improve the basic brain functions that cannot be consciously controlled. It is these initial overreactions that are likely to trigger the downstream malfunctions. That is why they could be the key to recovery.
The studies with former patients give hope, but they have a problem: the brain functions were measured retrospectively, but not in the acute state. It is therefore conceivable that the sufferers were doing very badly before the therapy, but that their brain activities were comparatively little changed at this point in time, and that this is precisely why they were able to recover. In other words: it is possible that the studies do not show the result of a recovery, but rather its neural prerequisite. Before and after studies are now being carried out in Heidelberg to check the results.
Triggered by hereditary and psycho-social factors
As with other mental illnesses, there is strong evidence that the disorder is triggered by hereditary and psycho-social factors. Borderliners are likely to come into the world with a particular sensitivity and then react more sensitively to what they experience. Many report having experienced neglect or violence in their childhood. An estimated 65 percent were sexually abused. But the injury is not always that obvious.
"This little child, which I actually was, I tucked away in some corner and never saw it again. And that certainly contributes to the emptiness when you have to put away a very important part of your identity and then can't look there for years, because that is associated with bad feelings. And then there is such a big, black hole. "
Mila has little memories of her mother: a woman with no interest in her child and inwardly absent. Her father was not there for her either, but instead demanded that she be there for him.
"So actually it's neglect from my mother's side and abuse from my father's side. Because my parents weren't really in the relationship any longer. And then my father looked for another emotional contact, and that was it I then, but I was a child. And then finally collapsed when my father looked for other women outside of marriage, and then I felt bad, I reproached him and not my mother. "
Therapies must be tailored to the disorder
"We know that today, and today we can say that it is not our fault. But we both wondered for a long time what we did wrong, that the mother does not love us. And why we have to make sure that she does goes well. And that's still the case today. "
Incidentally, this is also the reason why the two sisters only want to appear on the radio with a pseudonym - to protect their parents.
In the treatment of borderline, more and more studies show that therapies are especially effective when they are tailored to the disorder. Far too often today, borderliners are still treated in a clinic for eating disorders or for self-harm in psychiatry.
"There are really very good quality-tested centers that are specifically trained to work with borderline patients as inpatients. And then there are of course a large number of acute psychiatric treatments that are still overwhelmed by it and that are benevolent and benevolent but primarily for one provide short inpatient relief and then unintentionally often aggravate the problem, "says the Mannheim psychiatrist Bohus.
Two forms of therapy are particularly effective
Two forms of therapy in particular have proven to be effective in recent years. One of them is mentalization-based therapy. "Mentalization" refers to the ability to recognize how desires, ideas and thoughts lead to behavior. In the end, the borderliner understands himself and others better. The Briton Peter Fonagy, who helped develop mentalization-based therapy, explains it this way: "I think that you think that I think, therefore I am."
"If you just sit down and listen in therapy, you will achieve little. The disorder can even get worse. That is why MBT is a very active intervention. The patient has to feel that he is being recognized as a person, with his own wishes, his own Feelings and own intentions. When the other person notices that I, the patient, have control over my mind and my body and shows it to me, then I can trust them. And then I no longer have to be overly vigilant. "
Therapies with good results
The German S2 guidelines for personality disorders classify only one therapy as "specifically effective": DBT, the dialectical behavioral therapy, which is now carried out in 35 clinics - with good results. The psychiatrist Martin Bohus and his colleagues asked former patients about their health 15 years after their discharge: 70 percent say they lead a meaningful life, around 40 percent are even completely free of symptoms.
"In the scientific sense, these 70 percent no longer meet the criteria for a borderline disorder. The technical term means that this is a symptom reduction. But for a long time we were unsure whether a symptom reduction would actually improve our sensitivities. It can yes, that symptoms shift, that completely different problems arise, that we measure the wrong things. And yet we are quite satisfied that there is obviously a relatively high correlation between symptom reduction and improvement in life satisfaction. "
A very strong sensory stimulus against emotions
Skills training is at the center of the DBT. Skills such as inner mindfulness or dealing with other people are practiced. Mila also did the therapy ten years ago. Since then, she has always had an emergency bag with her, with everything she needs if she panics.
"Klimper, Klimper (...) Recently discovered and found to be very, very valuable, there are chilly gummy bears here. These are very hot gummy bears that I have in a box like this. (...) This is an idea from skill training that When I'm flooded with emotions, a very strong sensory stimulus can be helpful to feel myself again. There are very different possibilities. There is this ammonia story, people smell ammonia. And there are rubber bands that do you can be flicked on your skin. It just really hurts, so I'm occupied with this stimulus for the time being and can no longer worry about the other feelings. "
The DBT helped Mila cope with her everyday life: going to work and having a more or less stable relationship. Outwardly, she was under control and no longer showed any symptoms. That went well until, four years ago, Mila met a married man with whom she fell madly in love. Her newfound equilibrium began to shake.
In the dark corners inside
"And then there came the point where it said, and now we're also looking at the underlying, essentially very bad feelings. And then there is really an existential threat. When your parents don't notice you and let them down and you're a little kid, then you think you have to die. And those were the feelings that were triggered when he walked through the door. Then I thought I wouldn't survive this. "
Mila has gone back to her childhood, into the dark corners inside her, which she had kept hidden from herself for a long time, in order to finally understand what caused the great pain in her.
"But if you organize your whole life so that all these emotions must not be activated under any circumstances, then you cannot do a job because you are always somehow humiliated or misunderstood. You cannot have a sensible partnership because there is always danger If you really fall in love with someone, you can lose them again. That means they go around the world with a radar system that always says where one of these primary situations is threatening and I avoid that now. Exposure then means us teach the brain that these emotions are now survivable, tolerable. And for this we have to go back to this basic experience, as in classic trauma exposure, and convey to it, look, that was the case back then, it was bad, but today it is bearable. "
Faced with the past under guidance
Bohus and his colleagues at four psychiatric hospitals in Germany have started addressing the trauma of their patients as early as possible. After a three-week skills training session, exposure begins, in which the patient is confronted with the past again under guidance. Bohus is convinced that what works for patients with post-traumatic stress disorder also helps other borderliners.
"Overall, there is a risk that the focus will be on survival instead of a meaningful life for too long. In other words, that we fall short in the DBT as a whole, that we go too long on stabilization, but not on the basic emotional patterns. And We have now worked through it with PTSD, that it works and that it can be done quickly and that it has changed profoundly and are now working on applying this experience to the entire experience of borderline patients, namely these interpersonal traumatic experiences that are not sexual abuse, and working with exposure treatment there too, and the first data looks pretty good, so we think we'll see another breakthrough here in two years' time, and I think then we might have solved big problems with borderline disorder . "
Gaps in outpatient care
Just ten or 15 years ago, borderline was hardly curable. That has changed: Basic neuropsychological research offers the first building blocks for a neural model of the disease. The therapies are also evolving. It will be crucial that the findings from research are implemented as widely as possible. While the psychiatric wards in the hospitals are increasingly offering specific borderline treatment, there are still huge gaps in outpatient care. The DBT umbrella association, for example, has almost 60 resident psychotherapists throughout Germany who have appropriate additional training. Too few to prevent relapses.
Mila has now made it. She describes herself as a "dry bottom liner". During the last therapy, she trained as a naturopath for psychotherapy. Together with a colleague, she now coaches people with psychological problems herself, on an equal footing, with the special gaze of a former victim.
"A part of me will always be sad and may be, that will not go away. On the other hand, it is quite possible for us to live with the disorder without having to say, yes, I still have a disorder. I still have Difficulties, but who doesn't? I wouldn't sign that you just have this disease or disorder and have to live with it forever.
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