Heightened Emotional Sensitivity and
Transference in BPD
Glen O. Gabbard, M.D.
Brown Foundation Chair of Psychoanalysis
&
Professor of Psychiatry
Baylor College of Medicine
Training & Supervising Analyst
Houston-Galveston Psychoanalytic Institute
The Role of the Amygdala
The amygdala increases vigilance
The amygdala facilitates an individual’s
evaluation of threat or danger
BPD patients with histories of childhood
trauma have been shown to have
hyperreactive amygdalar responses
EI-I
- Herpertz et al., Biol Psych 50: 292-298, 2001 2
Medial Prefrontal
Cortex
Amygdala
Hypothalamus
Thalamus
Hippocampus
Orbital Prefrontal
Cortex
Response to Facial Expressions
BPD patients show significantly greater left
amygdalar activation to facial expressions
compared with normal controls
BPD patients attribute negative qualities to
neutral faces
- Donegan et al 2003
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5
Amygdala Hyperreactivity
(Ekman Faces)
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.
NC = normal control.
- Donegan et al. Biol Psych 2003;54:1284
Summed % signal change
Amygdala Hyperreactivity
35
30
25
20
15
10
5
0
NC
BPD
Neutral
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NC
BPD
Happy
NC
BPD
Sad
NC
BPD
Fearful
Left amygdala activation levels for individual subjects within
the NC and BPD groups for each of the 4 facial expressions.
- Donegan et al., Biol Psych 2003;54:1284
8
MR Volumetrics: Orbitofrontal
Cortex in BPD
13.79
10.5
15
10.59
Volume (cm3)
14
Volume (cm3)
12.12
13
12
11
10
9
8
L
= HC
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R
L
16
15
14
13
12
11
10
9
8
Control
BPD
= BPD
- van Elst et al., Biol Psych 2003;54:163
9
“Bottom-Up” Regulation of
Emotion
AMYGDALA
REFLEXIVE/AUTOMATIC
PROCESSES:
“BOTTOM-UP” REGULATION
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10
PREFRONTAL CORTEX:
“TOP-DOWN” REGULATION
AMYGDALA
REFLEXIVE/AUTOMATIC
PROCESSES:
“BOTTOM-UP” REGULATION
The Frontolimbic Network
The frontolimbic network appears to be central
to the emotional dysregulation in BPD
This network consists of:
anterior cingulate cortex (ACC)
orbitofrontal cortex (OFC)
dorsolateral prefrontal cortex (DPC)
hippocampus
amygdala
- Schmahl and Bremner, J Psych Res
EI-I
40:419-427, 2006
12
The Frontolimbic Network (cont.)
ACC may be viewed as the brain region mediating
emotion. Same brain areas are also involved in
dysfunctional serotonergic transmission,
associated
with impulsive aggression in BPD
The subgenual cingulate is involved with emotional
control, and studies show that it is deactivated in
response to stressful stimuli in BPD
ACC dysfunction is probably a key factor in the
emotional dysregulation seen in BPD
--Schmahl and Herpertz, J Psych Res 41:419-427, 2006
13
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Frontolimbic Inhibitory Function
BPD patients were asked to push a button
for words in standard font but not for
italicized words.
BPD patients were more impulsive than
controls, particularly when the italicized
words were negative.
In contrast to controls, BPD subjects showed
 amygdalar reaction and  activity in
subgenual cingulate and in medial OFC.
EI-I
- Silbersweig et al.: Am J Psych 164:1832-1841, 2007
15
Frontolimbic Inhibitory Function
(cont.)
Also in response to negative words,
BPD subjects showed  activity in the
dorsal ACC.
Hence even though they were not able
to exercise impulse control, they were
aware they had to devote other
resources to monitoring it.
EI-I
- Silbersweig et al.: Am J Psych 164:1832-1841, 2007
16
Neuroimaging data of adult BPD patients
suggest that amygdalar hypersensitivity
and emotional dysregulation
may be related to specific dysfunctions
in the prefrontal cortex
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
Heightened Emotional Sensitivity
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 Sensitivity (cont.)
Morphing of facial expressions is needed to
accurately assess the capacity of BPD patients to
respond to emotional expressions.
Faces change gradually and monotonically from
neutral to prototypical emotional expressions at
maximum intensity.
Allows assessment of how intense a facial
expression must be before accurately recognized.
EI-I
- Lynch et al, Emotion 4:647-655, 200620
Morphed Fear Faces – Within Person
Heightened Emotional Sensitivity (cont.)
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.
EI-I
- Lynch et al, Emotion 4:647-655, 2006
22
Heightened Emotional Sensitivity (cont.)
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.
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23
- Lynch et al, Emotion 4:647-655, 2006
How well do BPD patients
mentalize?
24
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Definition
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).
25
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Reading the Mind in the Eyes Test
(RMET)
26
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Reading Faces & BPD
30 patients with BPD compared with
25 healthy controls using RMET
BPD group performed significantly
better than healthy controls.
28
EI-I
- Fertuck et al, American Psychoanalytic Association, 2009
Reading 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.
EI-I
- Fertuck et al, American Psychoanalytic Association, 2009
30
Reading Faces & BPD (cont.)
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.
31
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Reading Faces & BPD (cont.)
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.
EI-I
32
Reading Trustworthiness
BPD group sees faces as less trustworthy
than controls
In contrast to trust, BPDs and controls
read fear similarly
BPD group takes longer to judge faces as
more trustworthy: also, shows more
decision uncertainty
EI-I
- Fertuck 200934
Paradox in the BPD Field
The so-called “radar” for the therapist’s
countertransference reflects the BPD
patients’ heightened capacity to read
early changes in facial expressions.
However, co-existing with this capacity
are misinterpretations that are quasidelusional.
EI-I
35
Donegan Subjects on Neutral Faces
“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”
EI-I
-
Donegan, Biological Psychiatry, 2003
36
Paradox in the BPD Field (cont.)
Heightened sensitivity may be both
accurate and inaccurate.
Accuracy probably varies depending on
the state of the attachment relationship,
the presence of powerful feelings, and
the degree of ambiguity of the facial
expression.
37
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Paradox 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.
38
EI-I
- Bateman & Fonagy, 2004
Clinical Implications
Clinician needs to be aware that the patient may be
accurately tuning in to a not-yet-conscious feeling
state in the therapist.
Clinicians must remember that neutral faces
represent the most ambiguous threat.
It is also possible that the patient may be
misinterpreting and overreacting to a small change
in facial expression.
Therapists must be aware of nonverbal
communications to patients.
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39
Emotion Recognition
BPD subjects have a bias towards
the perception of anger, rejection,
or social threat.
They see the world and others as
dangerous, and themselves as
powerless and unacceptable.
EI-I
- Domes et al, J Personality Disorders 23:6-19, 200940
Emotion Recognition (cont.)
Intact neurocircuitry within the
amygdala is essential for intact emotion
recognition.
Patients with lesions of the amygdaloid
complex show impaired recognition of
negative facial expressions.
- Adolphs et al, Nature 433:68-72, 2005
- Domes et al, J Personality Disorders 23:6-19, 200941
EI-I
Emotion Recognition (cont.)
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.
42
EI-I
Domes et al, J Pers Diorders 23:6-19,2009
Emotion Recognition (cont.)
Emotional arousal interferes with social
or cognitive processing and might
contribute to the characteristic
alterations in facial emotion recognition.
Maternal and romantic love activate an
attachment system that may deactivate
rational processing of feelings and
perceptions of others.
EI-I
- Bateman & Fonagy, 2004
43
Indications of Attachment Hyperactivity
in Core Symptoms of BPD
Pattern of unstable and intense interpersonal
relationships
Frantic efforts to avoid abandonment
Rapidly escalating tempo, moving from
acquaintance to great intimacy
- Bateman & Fonagy, 2004
44
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Pre-Mentalizing Modes of Subjectivity
in BPD: Psychic Equivalence Mode
Mind-world isomorphism
Mental reality = external reality
Intolerance of alternative perspectives—
reality is how I see things.
45
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Pre-Mentalizing Modes of Subjectivity
in BPD: Psychic Equivalence (cont.)
Perceived loss of attachment figure
 failure of mentalizing
 psychic equivalence
 intensification of unbearable affect
 self-harm or suicide attempt
46
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Attachment & 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.
47
EI-I
- Bateman & Fonagy 2004; Nemeroff
Animals with Early Adverse Experience cannot
use “social support” to buffer their stress responses
Mother’s presence did not buffer
physiological response to stress of
Abused infants in comparison to Controls
The presence of a social companion
buffers the HPA response to stress.
(Mat. Sep. monkeys lack this buffering
effect-not shown here)
Cortisol (ug/dl)
400
ACTH (pg/ml)
34
300
200
100
30
26
22
18
14
0
base pair alone
Stress Condition
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10
0 min
30 min
Time After Stress
48
What is
Mentalization-Based Therapy?
49
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An empirically validated therapy for MBT
8 year f/u study shows that it decreases
need for inpatient stay, reduces
suicidality, improves BPD symptoms and
maintains gains compared to controls.
EI-I
-Bateman and Fonagy 1999,2001,200850
Mentalization-Based Therapy
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
51
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Mentalization-Based Therapy (cont.)
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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
52
Active engagement with the patient
Mentalization-Based Therapy (cont.)
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
53
EI-I
Mentalization-Based Therapy (cont.)
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 54
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HOW DOES
EMPATHY
DIFFER FROM
MENTALIZATION?
55
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Empathy vs. Mentalizing
Empathy has three components:
An affective reaction that involves sharing of
another person’s emotional state
A cognitive capacity to imagine other
people’s perspectives
A stable ability to maintain a self-other
distinction
EI-I
- Choi-Kain & Gunderson, Am J Psychiatry
56
165:1127-1135, 2008
Empathy vs. Mentalizing
Both involve appreciation of mental states in
others
Empathy adds the dimensions of sharing in those
mental states and having empathic concern for
others
Empathy is more other-oriented while
mentalization is equally self- and other-oriented
Empathy involves cognitive skill and experience of
affect, but its content is primarily affectively
focused
EI-I
- Choi-Kain & Gunderson, Am J Psychiatry57
165:1127-1135, 2008
Implicit Mentalization
Unconscious, automatic, or
procedural operations of an
individual’s ability to imagine his
own and others’ mental states
Taking turns in conversation
58
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Explicit Mentalization
Deliberately makes conscious efforts
to know one’s own and others’
internal experiences
EI-I
A therapist actively and consciously
works to imagine the mental states
of the patient and encourages the
patient to do the same
59
Reflective functioning and BPD
Reflective functioning (RF) is predictive
of BPD diagnosis only in subjects with
history of abuse
Because RF varies depending on context,
the assessment of mentalization as a
marker of BPD remains problematic.
- Choi-Kain & Gunderson, Am J Psychiatry 165:1127-1135, 200860
EI-I
Mirror Neurons & Mentalization
The fundamental mechanism that allows us to
understand the actions and emotions of others
involves the activation of the mirror neuron system
for actions and the activation of viscero-motor
centers for the understanding of affect.
Action observation causes the automatic activation
of the same neural mechanism triggered by action
execution or even by the sound produced by the
same action.
EI-I
- Gallese et al, Trends in Cognitive Science 8:396-405, 2004
- Koehler et al, Science 97:846-848, 200262
Mirror 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
63
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64
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Mirror 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.
EI-I
- Fonagy 2009
- Brass & Haggard, Neuroscientist 14:319-325, 200865
CONCLUSIONS
BPD patients are unusually
perceptive but tend to misinterpret
trustworthiness
Mentalizing exists on a continuum
and is highly variable in BPD
66
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CONCLUSIONS
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Therapists must take into account
BOTH the possibility of accurate
perception of unconscious emotion
in the therapist AND the
transference-based
misinterpretation of those
perceptions
67