Before they even did any further testing, the researchers noticed that they had difficulty working with the nondiagnosed controls with negative affect and low effortful control. Even though these individuals were prescreened and did not meet the criteria for diagnosis with any personality disorder, they showed unreliability in keeping appointments, made frequent changes of address and phone number, and evinced heightened anxiety and paranoia regarding the experimental procedures. The researchers felt that this subset of the control group contained people whose behavior showed evidence of emotional dysregulation, even though they were functioning in school and did not meet the stringent criteria required for diagnosis of a personality disorder.
Test results surprisingly revealed that there was a single, but very distinct, difference between borderlines and the temperamentally similar controls: clinically diagnosed borderlines had much more difficulty in quickly resolving conflicting information than the temperamentally matched controls and the normal controls.
The ability to resolve conflicting information—an essential aspect of what is known as the executive attentional network—appears to be centered in the anterior cingulate cortex. This region undergoes substantial development relatively early in childhood, between the ages of two and seven years old. Posner and his colleagues hypothesized that “certain individuals possess a genetic propensity related to temperamental characteristics present prior to the disorder. Patients with borderline personality disorder often report incidents of abuse during childhood. These environmental events, together with the genetic propensity, may interfere with development of executive control, which in turn influences the ability to develop clear ideas and empathy for the minds of others as well as the experience of diffusion of one's own identity.”36 In summary then, a very difficult childhood can take a predisposition for borderline personality disorder and turn it into a devastating reality. A decent upbringing, however, can mean that a person with the same predisposition will grow up only to be difficult to deal with, but not necessarily someone who comes to the attention of a clinician.
Interestingly, Posner's work regarding the importance of the attentional network to borderline-like behavior ties neatly with Joseph Newman's work involving psychopathy. Newman, if you'll remember, proposed that psychopathy is actually a disorder related to the attentional network. In fact, just as diseases such as schizophrenia may be found in individuals with a wide variety of underlying personality traits, Newman has found evidence that psychopathy may be found in individuals with many different personalities. The underlying personality appears to shape the expression of the psychopathy. A nonviolent sort might become a con man, while a more violent type might become a hit man.
I can't help but remember Carolyn's brief visit to the store to pick up a few things—during which time she disappeared, to reappear in my life five years later. Once Carolyn's attention was turned to the man she met at the store, it seems, she lost focus on the fact that she was supposed to come back to the cabin and her waiting family.
Cognitive-Perceptual Impairment: Dorsolateral, Ventromedial, and Orbitofrontal Prefrontal Systems
The third type of dysfunction commonly seen in borderlines involves cognitive-perceptual impairment. More subtly, this might show itself as the philandering husband who accuses his faithful wife of cheating on him after he gives her venereal disease. Or the business executive who is unable to recognize that her “brilliant” financing strategy has so many obvious flaws that it will ruin the company. Stronger versions of this might manifest as the stroke victim who believes her husband's body has been taken over by an imposter. These types of cognitive-perceptual impairments relate to the dorsolateral prefrontal system, which underpins our ability to reason, to develop strategies for solving complex problems, to think abstractly, and to maintain a working memory. Strangely enough, people with damage to the dorsolateral and nearby ventromedial areas can have normal intelligence but have no common sense—they are unable to make reasonable decisions.
This phenomenon has been studied in relation to gambling experiments with play money. Players, including brain-damaged patients and normal controls, were given four stacks of cards to draw on—two of which were rigged to give large penalties, while the other two were rigged for small penalties. Unlike normal controls, brain-damaged patients, even those who became consciously aware that some decks were riskier than others, continued to play equally from all decks. Their skin showed no change in conductance, which indicated the patients’ lack of concern about their risky behavior. It is thought that this dysfunctional pattern of performance was due to the fact that the patients weren't able to develop an emotional “gut” feeling related to the high-risk decks—a theory known as the somatic-marker hypothesis.37 (Somatic is from the Greek word meaning “body.”) It seems that conscious, overt knowledge is not enough to ensure common sense decision-making ability; other neural circuits—with the surprising inclusion of those involved in emotion—play a powerful, but hidden, role.
Subtle brain damage has also been affiliated with odd “end justifies the means” behavior. Logically, it might seem rational, for example, to push a hefty man into the train's path to slow a train and save the lives of people farther down the tracks—but normal individuals just can't bring themselves to even think about doing it. Those with damage to their frontal lobes, on the other hand, can easily imagine pushing the man in front of a train to impede its motion and thus save other people's lives. (This example may seem a bit contrived, but it's the example that was presented to the test takers.) Brain-damaged individuals, it seems, focus primarily on the consequences, ignoring whatever nasty means might be involved. It may well be that subtly miswired or damaged neural circuits lie behind some of the can't-make-an-omelet-without-breaking-eggs type of behavior seen in dictators and their supporters as they justify the killing of thousands, or even millions, to further their goals.38
The medial orbitofrontal cortex appears to be particularly important in suppressing emotional memories that are irrelevant to the current situation. Thus, individuals with borderline personality disorder and its subclinical cousin often seem to respond in “characteristically inflexible and maladaptive ways based not upon current social contexts, but rather according to implicit emotional memories of past interpersonal experiences.”39 This inflexibility may well relate to orbitofrontal cortex dysfunction. Subclinical examples of such behavior might include the supervisor who refuses to see the need for spending money to update equipment despite obvious cost savings, or the father who beats his daughter for being late despite the fact that her car broke down. On a scale of wider importance, it might explain, for example, Hitler's utter inflexibility once he had made a decision.b.40 Borderlines, it should be noted, tend to become particularly irrational when strong emotions are stirred up.41
Interestingly enough, substance abuse also appears to produce prefrontal dysfunction, which has been associated with various aspects of addictive behavior and impaired decision making in people with antisocial personality disorder.42 Patients with borderline personality have been found to have similarly impaired decision-making ability and are thought to have dysfunction in the orbitofrontal region.43 And, of course, some individuals with borderline-like traits attempt to self-medicate with drugs or alcohol, worsening their already impaired prefrontal dysfunction.
Some studies have also shown that volumes of the left orbitofrontal cortex, right anterior cingulate cortex, amygdala, and the hippocampus are all smaller in patients with borderline personality disorder—the shrinkage forming a very distinctive pattern that might help distinguish borderline personality disorder from other disorders.44 Unfortunately, in a chicken and egg situation, it's not clear whether the smaller size of those neural features causes borderline personality disorder, or whether the disorder itself causes the deterioration. In one form of schizophrenia, for example, brain scans of affected children show a remarkable loss of gray matter in the cerebral cortex between the ages of thirteen and e
ighteen—the anatomical abnormalities mirrored the increasing psychotic symptoms.45 And in fact, there is an association between borderline personality disorder and schizotypal personality disorder (often thought to be a mild version of schizophrenia), as well as with schizophrenia itself.46 One study found reduced N-acetylaspartate (NAA) compounds in the dorsolateral prefrontal cortex in borderline patients. This is significant because NAA depletion, which has been observed in both adults and children with schizophrenia, reflects a state of neuronal damage that often precedes cell death.47
BUT WHAT'S THE BIG PICTURE?
At this point, it might be nice to paint a bold picture of precisely what is going awry in the neural circuits that handle emotional information processing, impulsivity, and cognitive-perceptual activity in people with borderline personality disorder. But, although researchers are zeroing in on a variety of differences between normal and borderline neural functioning, they still don't know enough about the many different signal pathways, or how defective signal pathways compensate, to be able to state definitely what is going on. In any case, it appears that many borderline features, including poorly regulated emotions, impulsivity, and identity disturbances, are caused by disrupted connections between the prefrontal cortex and other regions of the brain that underlie higher cognitive functions.48
Evidence from family studies strongly supports the separate inheritance of impulsivity, moodiness, and cognitive dysfunction—all of which are found in unfortunate confluence in a borderline. Mood and impulsivity traits, for example, are often found in relatives of borderlines, but piecemeal—one relative might have a mood disorder, while another may have problems with impulsivity. Inheritance of such traits means that some of the defects we see so clearly in medical imaging are almost certainly due to problematic genes. Genetic bad luck means getting the whole constellation of a predisposition toward borderline-like personality traits—or, in some cases, outright borderline personality disorder, even without obvious environmental stressors.
In summary, then, it seems that disrupted amygdala function may cause the negative emotions a borderline feels when he is first appraising a person or situation. Disrupted orbitofrontal cortex function may cause impulsivity. And disrupted hippocampal function can cause the typical difficulty a borderline has in ignoring emotional cues that are not relevant to the task at hand. (This would account for the irrational roommate described earlier who was unable to focus on the facts and instead overreacted to her own emotions.) A problematic anterior cingulate cortex may underpin a borderline's inability to resolve conflicting information, while dysfunction in the dorsolateral prefrontal cortex may be involved in the borderline's impaired ability to effectively reevaluate negative stimuli. Ultimately, some of these disrupted activities may be a consequence of reduced activity related to serotonin, particularly in the orbitofrontal cortex.
Underlying all of these issues are the borderline's problems with identity, which, as psychiatrists Katherine Putnam and Ken Silk note, “may be the most profound and damaging result of a chronic state of emotional dysregulation.” Problems with identity would include the chameleon-like behavior so often seen in borderlines, as well as the paradoxical mixtures of inflexibility and malleability.49 (This is much like Milosevic's inability to be swayed by reason or facts, coupled with his utter dependence on his wife, Mira.) Putnam and Silk add: “As emotional experience constitutes the most fundamental part of our selves, it is impossible to know who we are if we cannot identify our feelings, figure out what triggers them, and learn how to modify them to achieve our goals. This enduring frustration, which stems from this primary experience of dysregulation, is an integral part of the experience of BPD.”50
A LINK WITH THE IMMUNE SYSTEM?
Interesting hints have emerged in recent years that borderline and other personality disorders may be linked with abnormalities in the immune system.51 These ideas were first proposed by Russian scientists in the 1930s.52 The linkage the Russians proposed seemed so improbable, however, that it was ignored by the scientific community, even when the ideas were undergirded with more substantive research studies by George Solomon at Stanford in the 1960s. Part of the problem was that conventional research wisdom held that there was no connection between the immune and the neurological (behavioral) systems. Eventually a number of researchers discovered that the seemingly independent nervous and immune systems actually “speak” a similar chemical language that allows the two systems to interact with each other. Finding this connection has given impetus to the small but fascinating body of research that has recently been emerging in this area.
OVERLAPPING PERSONALITY DISORDERS
Borderline personality disorder often shades in with other personality disorders. One study of fifty-nine borderline patients found that all but one was also suffering from an Axis I disorder—almost 70 percent had three or more.53 The overlap with disorders such as depression, narcissism, and antisocial personality disorder can often make diagnosing the borderline into a complex chess game. If you clear up the depression, for example, will the borderline symptoms go away? Is the patient primarily suffering from antisocial personality disorder with some borderline co-symptoms? Or is he suffering from borderline personality disorder with some symptoms of antisocial personality disorder? Or perhaps the apparent overlap of disorders is just a tool employed by a compassionate doctor to obtain much needed insurance coverage.
But the traits of the different disorders overlap for good neurological reasons. Imaging studies of borderline patients as well as patients with antisocial personality, for example, show that both disorders, which share common attributes of impulsivity and cognitive dysfunction, have diminished regional cerebral blood flow in large areas of the right prefrontal and temporal cortex.54 Both disorders also show dysfunction in the frontal cortex and limbic systems, which do the heavy neural lifting involved in processing emotions. There are differences, however, which can be more or less distinct, depending on the symptoms of the patient. Borderlines possess general functional dysregulation, along with hair-trigger amygdalae that respond to even tiny emotional cues. Psychopaths, on the other hand, can sometimes show laid-back responses in the limbic system, including the amygdala, accompanied by revved-up prefrontal areas in response to emotional stimuli. Under fearful situations, however, the limbic and prefrontal areas in psychopaths swap their activation patterns.55 Notably, many of the “coping characteristics” of both disorders are precisely the same—projection, blame shifting, gaslighting, and narcissistic demands.
Fig. 8.11.
In the end, it is clear that human cognition is an extraordinarily slippery creature, which neuroscience is exposing as far less logical and more emotional than we had ever previously realized. This is true even for normal individuals. But for those with even a soupçon of personality disorder, it can be worse—sometimes far worse. Such irrationality can have lose-lose consequences. Not only is personality disorder associated with problematic and even sinister behavior, but it is also related to the naivete that can make relatively normal individuals such easy prey for Machiavellians.
But what is perhaps worst of all is that a person can appear entirely normal, free of any consequential diagnosis of personality disorder, yet have sometimes extraordinary deficiencies in his ability to reason. We saw this with Serbia's Slobodan Milosevic, who, it seems, fooled even himself into believing that the many wars he initiated and people killed were none of his own doing, or were trivial offenses, and that his destruction of the Serbian economy was beside the point.
But there is yet another example of a seemingly normal leader who masked deep cognitive dysfunction. A leader whose charm, duplicity, vindictiveness, and unparalleled desire for adulation, as we shall see, makes Milosevic look gentle by comparison.
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a.Many psychologists and psychiatrists prefer not to treat borderline patients, since their manipulative tactics can take a psychic toll. Ken Silk, on the other hand, is that rare therapist who truly l
ikes his borderline patients. He understands that their inability to grasp positive emotions, combined with the pervasive and unremitting emotional distress that borderlines experience, can make their lives into a veritable prison, not only for those with the disorder, but for those who are attempting to treat or help them. Silk's ability to deal so compassionately with borderlines may stem in part from his own strong ego boundaries. I once watched a conference audience fall raptly silent as Silk explained how he deals with middle-of-the-night suicidal phone calls, telling his patients: “We are both working very hard in the sessions to decrease your suicidality. But you also need to know that I do not keep special ideas or plans at home that would make you all of a sudden not suicidal. If I had such tools, I would, of course, use them in the office. So if you are really unsafe, then you should go to the emergency room and have the emergency room folks call me. But if you are feeling suicidal but know that you can be safe until the next appointment, then thanks for calling me and letting me know and we can concentrate on this in our next session.”
b.Hitler's utter inflexibility regarding decisions he had made could be awesome. Some who tried to counter what Hitler himself called his unshakable obstinacy found that their efforts were in vain and sometimes counterproductive. Toward the end, when it was suggested to him that some things might have been done differently, he exclaimed, “But don't you see I can not [sic] change!”
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