See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/24397942
Quieting the Affective Storm of Borderline Personality Disorder
Article in American Journal of Psychiatry · June 2009
DOI: 10.1176/appi.ajp.2009.08121836 · Source: PubMed
CITATIONS READS
17 994
5 authors, including:
Erin A Hazlett Antonia S New
Icahn School of Medicine at Mount Sinai Icahn School of Medicine at Mount Sinai
234 PUBLICATIONS 11,462 CITATIONS 207 PUBLICATIONS 8,746 CITATIONS
SEE PROFILE SEE PROFILE
Harold W Koenigsberg Larry J Siever
Icahn School of Medicine at Mount Sinai Icahn School of Medicine at Mount Sinai
124 PUBLICATIONS 4,902 CITATIONS 545 PUBLICATIONS 27,219 CITATIONS
SEE PROFILE SEE PROFILE
Some of the authors of this publication are also working on these related projects:
Regulating Emotional Responses to Spoken Comments and Visual Images Across the Affective Instability Spectrum: An fMRI Study View project
High risk View project
All content following this page was uploaded by Erin A Hazlett on 16 May 2014.
The user has requested enhancement of the downloaded file.
, Clinical Case Conference
From the Mount Sinai School of Medicine and James J. Peters VA Medical Center
Quieting the Affective Storm
of Borderline Personality Disorder
Marianne Goodman, M.D. moil, and her behavioral dyscontrol intensified. During
her mother’s depression, she felt alone, with no expecta-
tions placed upon her and no consequences for her be-
Erin A. Hazlett, Ph.D. havior. She describes the resulting lack of boundaries as
“reckless.” During that time, she experienced intense
Antonia S. New, M.D. suicidal ideation, lying in bed for hours crying and think-
ing about ways to die, and developed ways to seek oth-
Harold W. Koenigsberg, M.D. ers’ attention. By age 15, she had started cutting her
arms, primarily to demonstrate to others her inner pain.
Larry Siever, M.D. By age 16, her behaviors had escalated to truancy and
physical altercations with the police. In college, she con-
tinued self-injurious behaviors as both self-punishment
and a means to communicate her distress. Emptiness
pervaded her “80%” of the time. Though highly intelli-
Case Presentation gent, she underwent periods of confusion and inability
to think clearly, particularly when she was emotionally
“V” was a 22-year-old single Caucasian woman who re- upset and physically exhausted, which interfered with
sponded to a newspaper advertisement recruiting per- her ability to complete school assignments. She re-
sonality disorder research subjects. She reported over 10 mained distant from peers and was not involved in any
years of moodiness, anger dyscontrol, and periodic sui- romantic relationships. Despite these difficulties, she
cidal preoccupation. was able to graduate from college, complete her intern-
ship, and be hired for a job.
History
Family. V was the older of two children. She described Psychiatric. Despite frequent anger outbursts, cutting
her mother as a controlling person with whom she bat- episodes, and pleas for help, psychiatric intervention was
tled constantly. Her father was more engaging and re- not obtained until age 15 when her high school, which
laxed, and they enjoyed closeness dur- had had to call the police at least 10
ing her early years. When V was 12, it times concerning V, mandated an
evaluation. Ultimately V, who was in-
was discovered that her father was “It is the extreme creasingly isolated and sleeping 14–
having an extramarital affair. Despite
V’s efforts to convince him to remain sensitivity to context that 16 hours a day, was diagnosed with
with their family, her father left when V major depression. During her late ad-
was 13 to live with his girlfriend. This
generates the...dynamic olescence, she underwent two trials
of antidepressant medication but was
disruption greatly affected V, who was that provides the unique nonadherent. At no point in her life
forced to relocate with her mother and
brother to the Midwest, where she had psychological signature has she met criteria for mania or hy-
difficulty adjusting and meeting new pomania.
peers. Her mother became clinically
for borderline personality V’s treatment history included see-
ing eight different therapists, with
depressed and was unable to parent ef- disorder familiar to most treatment durations ranging from
fectively, creating the sense that V had
lost both parents. Her father remained clinicians.” two sessions to 13 months. Her most
on the East Coast and their contact was successful psychotherapy trial was a
limited to occasional phone calls until once-weekly supportive therapy dur-
her return East for college several years later. ing college with a female therapist whom she liked. How-
ever, the therapy was disrupted several times by V flee-
Developmental. As a c hild V was p re co c io us b ut ing and then returning. V believed she was “too
moody and unusually sensitive to physical experiences overwhelming” to sustain a relationship with any of her
such as hair brushing and to challenges to her auton- providers.
omy, responding with anger and near hysteria, at times Just prior to her joining the Mount Sinai Mood and Per-
losing appreciation of her surroundings. These episodes sonality Disorders Research Program, she was hospital-
occurred 3–4 times a week, but otherwise she was a well- ized after ingesting 12 paroxetine tablets during an in-
adjusted, energetic, curious child. However, after the take appointment at a community clinic. She later
breakup of her family at age 13, her baseline emotional described this as a purely communicative action in-
state was characterized by misery, despair, and inner tur- tended to convey the urgency of her need for therapy.
This article is discussed in an editorial by Dr. Oldham (p. 509).
522 ajp.psychiatryonline.org Am J Psychiatry 166:5, May 2009
, CLINICAL CASE CONFERENCE
Rather than speeding up the intake process, she was hos- TABLE 1. Assessments of Anger, Aggression, Impulsivity,
pitalized briefly. and Childhood Trauma in the Case Subject
Case Subject
Medical. V denied any significant medical conditions Assessment Scorea Normal Value
and was not taking any psychoactive medication.
Barratt Impulsivity Scale 61.31 61.15 (SD=12.23)
Trauma. While V denied any clear incidents of child- Buss Perry Aggression 84.12 68.2 (SD= 17.0)
Questionnaire
hood trauma, she did describe an “inappropriate physi-
Childhood Trauma
cal altercation” with her father at age 17. After V had Questionnaire
made a disrespectful comment to him, he slapped her Total score 77
face, at which point she pushed him. The fighting esca- Emotional abuse 21
lated until both were on the floor. Additionally, as a child, Physical abuse 18
her mother responded to her tirades by throwing water Sexual abuse 5
in her face. On the Childhood Trauma Questionnaire, she Emotional neglect 18
Physical neglect 8
endorsed elevated levels of both emotional neglect and
State-Trait Anger Expression
abuse and childhood physical abuse (Table 1). Inventory
Trait 33 17.9 (SD=4.9)
Treatment Course State 13 17.9 (SD= 5.3)
Expression 55 32.0 (SD= 13.6)
V entered a 1-year dialectical behavior therapy re-
Overt Aggression Scale, 17.5 2.02 (SD= 3.75)
search protocol studying the neurobiology of treatment aggression subscale
response. Because subjects remain off all psychiatric a Elevated values are in bold.
medications during the study, the Mount Sinai School of
Medicine and James J. Peters VA Medical Center institu-
tional review boards require regular consultation and re- research program which resulted in a temporary symp-
views by an outside physician to determine if psychiatric tomatic improvement.
medication is indicated. Over the Christmas season, treatment progress was
At the outset of treatment, V endorsed dramatic mood lost due to disruption of the dialectical behavior therapy
shifts, verbally explosive behavior, and awakening with schedule. Coupled with the interruption of V’s work rou-
suicidal ideation 3–4 days per week. She expressed ha- tine, her sense of abandonment escalated, and her in-
tred of her body and felt unattractive to men. She was tolerance of being alone resulted in a fugue-like state in
starting her first professional job and was nervous about which she walked alone late at night in dangerous
her ability to perform and interact with colleagues. She neighborhoods. Police were alerted and she was invol-
dreaded being alone and was particularly debilitated on untarily hospitalized for 5 days and medicated with
weekends. She noted that she had not cut herself in over high-dose antipsychotics, which left her sedated and
a year but was plagued by feelings of emptiness and dysarthric. Upon discharge, she stopped her medica-
questions pertaining to her sense of self. tions, returned to work, and negotiated her way back
The first 2 months of treatment focused on orientation into the treatment study after outside consultation was
to the dialectical behavior therapy method and fostering again obtained.
a therapeutic alliance. The study therapist was a sea- Months 6–9 were marked by the beginnings of produc-
soned psychologist with years of experience with person- tive discussions about psychological triggers and strate-
ality disorder patients who is herself blind. The thera- gies for improved emotion regulation and building a
pist’s blindness had previously not interfered with her more fulfilling life. She began to employ more effective
treatment of other patients but proved problematic with strategies at work and with her roommate and family
V. Within the first few weeks, V was endorsing deliberate members. Despite this progress, copious session time
self-harm on several occasions, but refusing to show the was spent addressing treatment-interfering behaviors,
cut marks to the research staff and leaving sessions including protracted silences, storming out of the office,
when confronted. The study psychologist felt the inabil- and threats of quitting.
ity to “see” V was becoming an obstacle. The last 3 months of the treatment were consumed by
At the 3-month mark, V was transferred to the study the emotional reactions and practical decisions required
principal investigator (M.G.) for the duration of the trial. after her mother became critically ill and almost died.
Months 3–5 were notable for continued suicidality, Behavioral analyses of targets including increased anxi-
complaints that she “was dying,” and a determination ety reactions, newly reported binge eating episodes, and
to communicate through action the degree of her dis- excessive lethargy revealed distorted cognitive beliefs
tress. She purchased psychiatric medications online in a about her neediness, fears of abandonment, and guilty
plan to overdose but relinquished her “stash” to her feelings of how her emotional sensitivity as a child af-
therapist. On another occasion, hospital security inter- fected the family and overwhelmed her mother’s ability
vened when V abruptly left a session after refusing to to cope. She questioned how she might handle her
discuss her suicidality. Discussion in our weekly dialecti- mother’s illness and whether she was capable of caring
cal behavior therapy consultation group led to plans to for anyone else, believing she never received adequate
transfer V out of the research study into our outpatient nurturance as a child.
clinic for pharmacologic stabilization. This process be- A hiatus in the therapy occurred when V traveled to
came entangled with V’s fears of abandonment and the help her mother’s convalescence, which resulted in an
belief that she was “too overwhelming” for others to opportunity to renegotiate their relationship and
handle. Consultation by an outside psychiatrist, as stip- mend past misunderstandings. She returned more
ulated by our institutional review boards, was per- hopeful, less steeped in the past, and with a dimin-
formed. The consultant supported her remaining in the ished need to communicate through acting out. During
Am J Psychiatry 166:5, May 2009 ajp.psychiatryonline.org 523
, CLINICAL CASE CONFERENCE
FIGURE 1. Affective Startle Modification During Picture Processinga
Unpleasant Neutral Pleasant
80
Healthy individual
70 Borderline personality
disorder subject
Startle Eyeblink Amplitude
(% Change from Baseline)
60
50
40
30
20
10
0
Early Late Early Late Early Late
a Mean startle eyeblink amplitude (calculated as % change from baseline) shown for the borderline personality disorder patient and an age-
and sex-matched comparison subject. The experiment was divided into early and late trials to examine habituation effects.
FIGURE 2. Subjective Ratings of Unpleasant, Neutral, and A battery of self-report symptom measures was admin-
Pleasant Picturesa istered yielding elevated levels of negative affect, aggres-
sion, and anger expression (Table 1).
9
1=Very Pleasant, 5=Neutral,
The patient participated in a study examining the neu-
Healthy individual
8 ral circuitry of emotion-processing deficits in borderline
9=Very Unplesant
Borderline personality
7 disorder subject personality disorder. This study involves measuring startle
eyeblink and fMRI (separate sessions) while viewing a se-
6
ries of photographic images that vary in affective valence
5 (unpleasant, neutral, and pleasant). The patient’s results
4
were contrasted with those of a female healthy compari-
son subject. These data are anecdotal and meant to be il-
3 lustrative given that a large sample size and statistical
2 analysis is necessary in order to draw meaningful scien-
Unpleasant Neutral Pleasant tific conclusions.
a The borderline personality disorder patient rated all three picture Affective startle is a reliable nonverbal psychophysio-
types as slightly more unpleasant than the healthy comparison logical method that is useful for objectively quantifying
subject.
the waxing and waning of emotional processing. The
acoustic startle eyeblink response is a component of the
this time, she also started and nurtured a romantic re- whole-body startle reflex which occurs when a brief star-
lationship and secured a better job placement. How- tling stimulus (white noise burst, 105 db, 50-msec dura-
ever, productive gains triggered abandonment anxi- tion) is presented through headphones. The amplitude of
eties, stemming from a belief that people will leave her
the startle eyeblink response can be measured from elec-
if she “becomes too healthy.” She responded to these
tromyographic activity using miniature electrodes placed
fears by threats or actual engagement in self-destruc-
around the eye. Unpleasant, neutral, and pleasant pic-
tive behaviors. While the termination process was diffi-
cult and old behavioral patterns reemerged briefly, she
tures are presented for 6 seconds and the startle stimulus
was able to transition to a new treatment team and to is presented 4–5 seconds after picture onset on some tri-
articulate the numerous gains of her year of dialectical als. Numerous studies (e.g., reviewed by Lang et al. [1])
behavior therapy. have shown that in healthy individuals, the unpleasant
pictures (e.g., a man hitting a woman) prompt larger star-
Research Data tle eyeblink amplitude than pleasant (e.g., smiling baby),
while startle amplitude during neutral pictures is interme-
Structured clinical interviews for axis I and II disorders diate (e.g., neutral face). Figure 1 shows the healthy com-
yielded the following: borderline personality disorder, past parison subject exhibited the normal affective startle pat-
major depressive disorder, and verbal intermittent explo- tern of larger startle eyeblink response amplitude during
sive disorder. unpleasant pictures and smaller amplitude during pleas-
524 ajp.psychiatryonline.org Am J Psychiatry 166:5, May 2009
Quieting the Affective Storm of Borderline Personality Disorder
Article in American Journal of Psychiatry · June 2009
DOI: 10.1176/appi.ajp.2009.08121836 · Source: PubMed
CITATIONS READS
17 994
5 authors, including:
Erin A Hazlett Antonia S New
Icahn School of Medicine at Mount Sinai Icahn School of Medicine at Mount Sinai
234 PUBLICATIONS 11,462 CITATIONS 207 PUBLICATIONS 8,746 CITATIONS
SEE PROFILE SEE PROFILE
Harold W Koenigsberg Larry J Siever
Icahn School of Medicine at Mount Sinai Icahn School of Medicine at Mount Sinai
124 PUBLICATIONS 4,902 CITATIONS 545 PUBLICATIONS 27,219 CITATIONS
SEE PROFILE SEE PROFILE
Some of the authors of this publication are also working on these related projects:
Regulating Emotional Responses to Spoken Comments and Visual Images Across the Affective Instability Spectrum: An fMRI Study View project
High risk View project
All content following this page was uploaded by Erin A Hazlett on 16 May 2014.
The user has requested enhancement of the downloaded file.
, Clinical Case Conference
From the Mount Sinai School of Medicine and James J. Peters VA Medical Center
Quieting the Affective Storm
of Borderline Personality Disorder
Marianne Goodman, M.D. moil, and her behavioral dyscontrol intensified. During
her mother’s depression, she felt alone, with no expecta-
tions placed upon her and no consequences for her be-
Erin A. Hazlett, Ph.D. havior. She describes the resulting lack of boundaries as
“reckless.” During that time, she experienced intense
Antonia S. New, M.D. suicidal ideation, lying in bed for hours crying and think-
ing about ways to die, and developed ways to seek oth-
Harold W. Koenigsberg, M.D. ers’ attention. By age 15, she had started cutting her
arms, primarily to demonstrate to others her inner pain.
Larry Siever, M.D. By age 16, her behaviors had escalated to truancy and
physical altercations with the police. In college, she con-
tinued self-injurious behaviors as both self-punishment
and a means to communicate her distress. Emptiness
pervaded her “80%” of the time. Though highly intelli-
Case Presentation gent, she underwent periods of confusion and inability
to think clearly, particularly when she was emotionally
“V” was a 22-year-old single Caucasian woman who re- upset and physically exhausted, which interfered with
sponded to a newspaper advertisement recruiting per- her ability to complete school assignments. She re-
sonality disorder research subjects. She reported over 10 mained distant from peers and was not involved in any
years of moodiness, anger dyscontrol, and periodic sui- romantic relationships. Despite these difficulties, she
cidal preoccupation. was able to graduate from college, complete her intern-
ship, and be hired for a job.
History
Family. V was the older of two children. She described Psychiatric. Despite frequent anger outbursts, cutting
her mother as a controlling person with whom she bat- episodes, and pleas for help, psychiatric intervention was
tled constantly. Her father was more engaging and re- not obtained until age 15 when her high school, which
laxed, and they enjoyed closeness dur- had had to call the police at least 10
ing her early years. When V was 12, it times concerning V, mandated an
evaluation. Ultimately V, who was in-
was discovered that her father was “It is the extreme creasingly isolated and sleeping 14–
having an extramarital affair. Despite
V’s efforts to convince him to remain sensitivity to context that 16 hours a day, was diagnosed with
with their family, her father left when V major depression. During her late ad-
was 13 to live with his girlfriend. This
generates the...dynamic olescence, she underwent two trials
of antidepressant medication but was
disruption greatly affected V, who was that provides the unique nonadherent. At no point in her life
forced to relocate with her mother and
brother to the Midwest, where she had psychological signature has she met criteria for mania or hy-
difficulty adjusting and meeting new pomania.
peers. Her mother became clinically
for borderline personality V’s treatment history included see-
ing eight different therapists, with
depressed and was unable to parent ef- disorder familiar to most treatment durations ranging from
fectively, creating the sense that V had
lost both parents. Her father remained clinicians.” two sessions to 13 months. Her most
on the East Coast and their contact was successful psychotherapy trial was a
limited to occasional phone calls until once-weekly supportive therapy dur-
her return East for college several years later. ing college with a female therapist whom she liked. How-
ever, the therapy was disrupted several times by V flee-
Developmental. As a c hild V was p re co c io us b ut ing and then returning. V believed she was “too
moody and unusually sensitive to physical experiences overwhelming” to sustain a relationship with any of her
such as hair brushing and to challenges to her auton- providers.
omy, responding with anger and near hysteria, at times Just prior to her joining the Mount Sinai Mood and Per-
losing appreciation of her surroundings. These episodes sonality Disorders Research Program, she was hospital-
occurred 3–4 times a week, but otherwise she was a well- ized after ingesting 12 paroxetine tablets during an in-
adjusted, energetic, curious child. However, after the take appointment at a community clinic. She later
breakup of her family at age 13, her baseline emotional described this as a purely communicative action in-
state was characterized by misery, despair, and inner tur- tended to convey the urgency of her need for therapy.
This article is discussed in an editorial by Dr. Oldham (p. 509).
522 ajp.psychiatryonline.org Am J Psychiatry 166:5, May 2009
, CLINICAL CASE CONFERENCE
Rather than speeding up the intake process, she was hos- TABLE 1. Assessments of Anger, Aggression, Impulsivity,
pitalized briefly. and Childhood Trauma in the Case Subject
Case Subject
Medical. V denied any significant medical conditions Assessment Scorea Normal Value
and was not taking any psychoactive medication.
Barratt Impulsivity Scale 61.31 61.15 (SD=12.23)
Trauma. While V denied any clear incidents of child- Buss Perry Aggression 84.12 68.2 (SD= 17.0)
Questionnaire
hood trauma, she did describe an “inappropriate physi-
Childhood Trauma
cal altercation” with her father at age 17. After V had Questionnaire
made a disrespectful comment to him, he slapped her Total score 77
face, at which point she pushed him. The fighting esca- Emotional abuse 21
lated until both were on the floor. Additionally, as a child, Physical abuse 18
her mother responded to her tirades by throwing water Sexual abuse 5
in her face. On the Childhood Trauma Questionnaire, she Emotional neglect 18
Physical neglect 8
endorsed elevated levels of both emotional neglect and
State-Trait Anger Expression
abuse and childhood physical abuse (Table 1). Inventory
Trait 33 17.9 (SD=4.9)
Treatment Course State 13 17.9 (SD= 5.3)
Expression 55 32.0 (SD= 13.6)
V entered a 1-year dialectical behavior therapy re-
Overt Aggression Scale, 17.5 2.02 (SD= 3.75)
search protocol studying the neurobiology of treatment aggression subscale
response. Because subjects remain off all psychiatric a Elevated values are in bold.
medications during the study, the Mount Sinai School of
Medicine and James J. Peters VA Medical Center institu-
tional review boards require regular consultation and re- research program which resulted in a temporary symp-
views by an outside physician to determine if psychiatric tomatic improvement.
medication is indicated. Over the Christmas season, treatment progress was
At the outset of treatment, V endorsed dramatic mood lost due to disruption of the dialectical behavior therapy
shifts, verbally explosive behavior, and awakening with schedule. Coupled with the interruption of V’s work rou-
suicidal ideation 3–4 days per week. She expressed ha- tine, her sense of abandonment escalated, and her in-
tred of her body and felt unattractive to men. She was tolerance of being alone resulted in a fugue-like state in
starting her first professional job and was nervous about which she walked alone late at night in dangerous
her ability to perform and interact with colleagues. She neighborhoods. Police were alerted and she was invol-
dreaded being alone and was particularly debilitated on untarily hospitalized for 5 days and medicated with
weekends. She noted that she had not cut herself in over high-dose antipsychotics, which left her sedated and
a year but was plagued by feelings of emptiness and dysarthric. Upon discharge, she stopped her medica-
questions pertaining to her sense of self. tions, returned to work, and negotiated her way back
The first 2 months of treatment focused on orientation into the treatment study after outside consultation was
to the dialectical behavior therapy method and fostering again obtained.
a therapeutic alliance. The study therapist was a sea- Months 6–9 were marked by the beginnings of produc-
soned psychologist with years of experience with person- tive discussions about psychological triggers and strate-
ality disorder patients who is herself blind. The thera- gies for improved emotion regulation and building a
pist’s blindness had previously not interfered with her more fulfilling life. She began to employ more effective
treatment of other patients but proved problematic with strategies at work and with her roommate and family
V. Within the first few weeks, V was endorsing deliberate members. Despite this progress, copious session time
self-harm on several occasions, but refusing to show the was spent addressing treatment-interfering behaviors,
cut marks to the research staff and leaving sessions including protracted silences, storming out of the office,
when confronted. The study psychologist felt the inabil- and threats of quitting.
ity to “see” V was becoming an obstacle. The last 3 months of the treatment were consumed by
At the 3-month mark, V was transferred to the study the emotional reactions and practical decisions required
principal investigator (M.G.) for the duration of the trial. after her mother became critically ill and almost died.
Months 3–5 were notable for continued suicidality, Behavioral analyses of targets including increased anxi-
complaints that she “was dying,” and a determination ety reactions, newly reported binge eating episodes, and
to communicate through action the degree of her dis- excessive lethargy revealed distorted cognitive beliefs
tress. She purchased psychiatric medications online in a about her neediness, fears of abandonment, and guilty
plan to overdose but relinquished her “stash” to her feelings of how her emotional sensitivity as a child af-
therapist. On another occasion, hospital security inter- fected the family and overwhelmed her mother’s ability
vened when V abruptly left a session after refusing to to cope. She questioned how she might handle her
discuss her suicidality. Discussion in our weekly dialecti- mother’s illness and whether she was capable of caring
cal behavior therapy consultation group led to plans to for anyone else, believing she never received adequate
transfer V out of the research study into our outpatient nurturance as a child.
clinic for pharmacologic stabilization. This process be- A hiatus in the therapy occurred when V traveled to
came entangled with V’s fears of abandonment and the help her mother’s convalescence, which resulted in an
belief that she was “too overwhelming” for others to opportunity to renegotiate their relationship and
handle. Consultation by an outside psychiatrist, as stip- mend past misunderstandings. She returned more
ulated by our institutional review boards, was per- hopeful, less steeped in the past, and with a dimin-
formed. The consultant supported her remaining in the ished need to communicate through acting out. During
Am J Psychiatry 166:5, May 2009 ajp.psychiatryonline.org 523
, CLINICAL CASE CONFERENCE
FIGURE 1. Affective Startle Modification During Picture Processinga
Unpleasant Neutral Pleasant
80
Healthy individual
70 Borderline personality
disorder subject
Startle Eyeblink Amplitude
(% Change from Baseline)
60
50
40
30
20
10
0
Early Late Early Late Early Late
a Mean startle eyeblink amplitude (calculated as % change from baseline) shown for the borderline personality disorder patient and an age-
and sex-matched comparison subject. The experiment was divided into early and late trials to examine habituation effects.
FIGURE 2. Subjective Ratings of Unpleasant, Neutral, and A battery of self-report symptom measures was admin-
Pleasant Picturesa istered yielding elevated levels of negative affect, aggres-
sion, and anger expression (Table 1).
9
1=Very Pleasant, 5=Neutral,
The patient participated in a study examining the neu-
Healthy individual
8 ral circuitry of emotion-processing deficits in borderline
9=Very Unplesant
Borderline personality
7 disorder subject personality disorder. This study involves measuring startle
eyeblink and fMRI (separate sessions) while viewing a se-
6
ries of photographic images that vary in affective valence
5 (unpleasant, neutral, and pleasant). The patient’s results
4
were contrasted with those of a female healthy compari-
son subject. These data are anecdotal and meant to be il-
3 lustrative given that a large sample size and statistical
2 analysis is necessary in order to draw meaningful scien-
Unpleasant Neutral Pleasant tific conclusions.
a The borderline personality disorder patient rated all three picture Affective startle is a reliable nonverbal psychophysio-
types as slightly more unpleasant than the healthy comparison logical method that is useful for objectively quantifying
subject.
the waxing and waning of emotional processing. The
acoustic startle eyeblink response is a component of the
this time, she also started and nurtured a romantic re- whole-body startle reflex which occurs when a brief star-
lationship and secured a better job placement. How- tling stimulus (white noise burst, 105 db, 50-msec dura-
ever, productive gains triggered abandonment anxi- tion) is presented through headphones. The amplitude of
eties, stemming from a belief that people will leave her
the startle eyeblink response can be measured from elec-
if she “becomes too healthy.” She responded to these
tromyographic activity using miniature electrodes placed
fears by threats or actual engagement in self-destruc-
around the eye. Unpleasant, neutral, and pleasant pic-
tive behaviors. While the termination process was diffi-
cult and old behavioral patterns reemerged briefly, she
tures are presented for 6 seconds and the startle stimulus
was able to transition to a new treatment team and to is presented 4–5 seconds after picture onset on some tri-
articulate the numerous gains of her year of dialectical als. Numerous studies (e.g., reviewed by Lang et al. [1])
behavior therapy. have shown that in healthy individuals, the unpleasant
pictures (e.g., a man hitting a woman) prompt larger star-
Research Data tle eyeblink amplitude than pleasant (e.g., smiling baby),
while startle amplitude during neutral pictures is interme-
Structured clinical interviews for axis I and II disorders diate (e.g., neutral face). Figure 1 shows the healthy com-
yielded the following: borderline personality disorder, past parison subject exhibited the normal affective startle pat-
major depressive disorder, and verbal intermittent explo- tern of larger startle eyeblink response amplitude during
sive disorder. unpleasant pictures and smaller amplitude during pleas-
524 ajp.psychiatryonline.org Am J Psychiatry 166:5, May 2009
