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September 12, 2011
Dr. Aaron T. Beck wrote: Dear Amy, I just came across an article(1), in which neurophysiological processes in Borderline Personality Disorder were compared with normal controls. Basically, what the authors found was that borderlines, responding to aversive stimuli showed the usual activation of the amygdala. However, when they were asked to reframe the response ("it is not real, it's only a picture?" or, react as an observer rather than as a participant), the borderlines showed an attenuated response in the dorsolateral prefrontal lobe and a sustained amygdala response. This is a rather graphic illustration of what we see in borderlines, specifically they have difficulty reframing their responses. So the picture is something like this: they are ultrasensitive to all kinds of events and respond with anxiety set as anger, etc (they score high on almost all of the dysfunctional attitudes on the DAS). They also have really poor impulse control. What this adds up to is that the best way to calm them down emotionally (the amygdala) is through the kind of strategies, suggested by Linehan and other DBT people, specifically self-soothing, acceptance, relaxation, and meditation. These are more likely, at least at the beginning, to reduce amygdala activity. Such strategies also help with engagement. After the patient is well into the self-soothing it may be possible to experiment with reframing. It might be best to start off with examples and see how the patient responds to them. The patient might be given an example not quite relevant to her and can practice alternative explanations, looking for evidence, etc. This is the kind of approach that we use with delusional patients. As the patient practices on the reframing of pseudo-examples, then it is possible to try some examples, from the patient's own repertoire. Do let me know what you think of this approach. Best, Dr. Beck Dr. Amy Cunningham wrote: Hi Dr Beck, Thank you so much for this! I completely agree that people with BPD struggle significantly with cognitive restructuring and reframing emotionally evoking situations. I often find that the patients experience the suggestion of reframing as invalidating the extent of their pain. I agree with your remark about their ultrasensitivity - I often explain the sensitivity as pains to patients comparable to an "emotional burn victim". I completely agree that validation and self-soothing allow the person to be in a place where she can start to examine her cognitive distortions and search for more flexible ways of thinking about the situation. I find psychological flexibility, to be a central goal for my work with people with BPD. I also find it helpful to start with validation of their extreme emotional response, as it greatly assists with engagement, and allows the person to be willing, instead of willfully defending her position. I am very much looking forward to working with CTT and Women's Space in helping them provide more effective services to people with BPD. Best, Amy

Schulze, L., Domes, G., Kruger, A., Berger, C., Fleischer, M., Prehn, K., Schmahl, C., Grossmann, A., Hauenstein, K., & Herpertz, S.C. (2011). Neuronal Correlates of Cognitive Reappraisal in Borderline Patients with Affective Instability. Biological Psychiatry, 69, 6, 564-573.