we have a a whole recipe book of diagnoses called the DSM IV-TR
, soon to be replaced by the DSM-V. The original DSM
was derived from an army handbook used by psychiatrists in WWII, much of which was taken from handbooks developed by German psychiatrists from their observations in the late 19th century. The rest of the army handbook was derived from psychoanalytic thinking -- the theories of Freud
and his followers. In the DSM I (1952), there were two kinds of illnesses, for the most part, psychosis and neurosis. Psychotic illnesses were defined by a break from reality (as in paranoid or religious
delusions in schizophrenia
or manic psychosis), and neurotic illnesses were considered to be reactions to psychological stressors and events.
There is also currently a category of illness that has to do with coping skills and temperament called the "personality disorders." It's not a particularly good term, and I wish they had thought of another -- "I'm sorry, your diagnosis is a disordered personality" is not a particularly useful approach to helping people.
For the longest time, it was thought that psychotic illnesses were more genetic/organic, and neurotic illnesses (such as depressive illness, or post-traumatic stress disorder) were reactions to stress and more amenable to treatment by psychotherapy. A type of personality disorder called "borderline personality disorder" was an exception to the neurotic rule - those afflicted tended to unravel and even appear to be psychotic while receiving the old-fashioned on the couch free association type of therapy called psychoanalysis. That's where the name "borderline" came from in the first place - it was thought to be on the "borderline" between psychosis and neurosis.
What is borderline personality disorder? It describes a type of temperament and coping, usually in women but found in men also, where someone is highly sensitive, prone to dramatic relationships, depression, anxiety, addiction, eating disorders, and self-injurious behavior such as cutting. It is very common, with nearly 6% of the population affected. Unlike depression which tends to come and go over the years, personality disorder symptoms are more stable and chronic, though for most people, borderline symptoms do tend to get better over the decades as we live and learn.
Borderline personality disorder most often develops in someone who was abused as a child, but people can have it without ever being abused. Usually it happens in those cases when there is a mismatch of temperament between parent and child. More modern types of therapy can be helpful for the symptoms, but you can only imagine what it must have been like to have borderline personality disorder and to feel unsure and anxious, free associating on the couch while your therapist said very little back in the psychoanalytic days. That kind of therapy would be like re-experiencing the neglect and abuse of childhood in its own way, and that is why psychoanalysis could make borderline personality disorder worse. Ultimately, borderline and some of the other personality disorders can get better as people learn to feel worthy and loved.
But, like everything else, we've discovered that even the personality disorders have biological underpinnings. I'm not sure why people continue to be surprised by these findings - it all happens in our bodies, and is thus mediated by biochemistry. In the case of borderline personality disorder, a paper and editorial in the American Journal of Psychiatry explore a link between borderline symptoms and opiate receptors.
We all have opiate receptors. They are activated by our natural endorphins, and can help with pain relief and relaxation. Opiate receptors are also activated by opiates derived from the opium poppy -- morphine, oxycodone, heroin, vicodin, percocet, etc. etc. etc. There are opiate activators found in certain varieties of food, most notably wheat (the exorphins) and milk (beta casein A1). We can increase our own endorphin activity through several behaviors - exercise, binging, binging and purging, and self-injury
. (While self-injury is a risk factor for eventual suicide
, in general people do not engage in cutting as a suicide attempt, but rather the painful act relieves anxiety and focuses psychic pain on a physical level). The placebo
effect is also thought to be mediated through activation of the endorphin system (1
In the paper, scientists measured how an opiate binder called [11C]carfentanil showed up in the brain of living borderline patients with a history of self-injury and in normal controls. They found pretty significant differences within the two groups, suggesting that the patients with borderline personality disorder who self-injure have differences in their opiate systems. Other studies have shown that people who engage in self-injurious behavior such as cutting have lower levels of endoprhins in the blood at baseline and differences in their endorphin genes compared to non-injurers.
Our endorphins regulate many of our social interactions, and almost anything we do to self-soothe, from childhood on, will activate our endorphin system. A certain subset of people, self-injurers in particular, will have less ability to self-soothe that seems to be genetically mediated, so they may go to more desperate measures (binging, addiction, self-injury) in an attempt to feel better. The same endorphin system deficit can explain some of the social problems that people with borderline personality disorder experience.
There are many levels of speculation to engage in at this point. The deficits run in families, and anyone can see how anxious, addiction-prone families can lead to less than optimal conditions for a growing child trying to find his or her way. Epigenetics may well play a role. Add chronic stress and inflammation, poor health, and poor diet - there's a whole recipe for generation after generation of biologically mediated mental distress. Fortunately, as we develop more understanding of the underpinnings of these conditions, we can start helping people with specific and sensible treatments. Overall, developing strengths in healthy self-care and self-soothing is the key to success in getitng past problematic behaviors such as self-injury.
Copyright Emily Deans, MD