Neurobiology of Self-Harm in Borderline Personality Disorder · Non-suicidal self-injury (NSSI) in...
Transcript of Neurobiology of Self-Harm in Borderline Personality Disorder · Non-suicidal self-injury (NSSI) in...
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Neurobiology of Self-Harm inBorderline Personality Disorder
Christian SchmahlDept. of Psychosomatic Medicine and
Psychotherapy, Central Institute of Mental Health
Mannheim, Germany
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Non-suicidal self-injury (NSSI) in BPD
• Non-suicidal self injury (NSSI): deliberate destruction of bodytissue without suicidal intent (APA, 2013)
• 50-80% of individuals with Borderline Personality disorder (Snir,
Rafaeli, Gadassi, Berenson, & Downey, 2015) and 46.2-60% of mentally illyouth engage in NSSI (Groschwitz et al., 2015; Kaess et al., 2013)
• Long lasting damage for concerned individuals, higher risk forsuicidal behavior (Guan, Fox, & Prinstein, 2012) and high costs for healthcare system (Wunsch, Kliem, & Kroger, 2014)
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Emotion dysregulation
Overview
Pain ProcessingSocial Interaction
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Plener et al., 2015
Non-suicidal self-injury in adolescence
NSSI
BorderlinePD
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Motives for NSSI in BPD
Kleindienst et al., JNMD, 2008
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Assessment of fluctuating data in daily life: EMA
Ecological momentary assessment (EMA)
• Real life and real time data
• Avoiding recall bias
• Accurate tracking of fluctuating variables (e.g.affect, hormones)
• e.g. Smartphone App based interventions,daily diary
• Different forms of assessment:
• Random prompts
• Event based prompts
• Mixed design
Source:https://www.movisens.co
m/en/products/movisensxs/
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Affective Dysregulation
Controls75
Borderline72n=
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l of
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Stiglmayr et al., Acta Psychatr Scand 2005Santangelo et al.,
J Abnorm Psychology 2015
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Change in Emotions after NSSI
Kranzler et al. 2018
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EMA- Study Design
Random Prompt:
MDBF
PANAS (selection)
DSS-4
Interpersonal
events
NSSI urge(urge > 6 & nssi event > 1)
NSSI event (< 30 min. )
Self-initiated
prompt: NSSI act
PANAS, MDBF,
DSS-4,
Interpersonal
events
End Random Prompt
NSSI act
Time passed by
Saliva sample
Method
Effect
Motive
Severity
Pain during NSSI/
Actual Pain
Control condition:
Saliva sample
Follow ups:
10, 20, 30 min. post
Affect, DSS-4
Saliva samples
Follow ups:
10, 20, 30 min. post
NSSI
Saliva samples
DSS-4/affect/pain
Pre
NSSI
saliva
sample
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NSSI and ß-endorphin
• Endogenous Opioid System (EOS):
• Three classes of opioids: β-endorphin,enkephalin and dynorphin (μ-, δ-, and ҡ-opioid
receptors; Dhawan et al., 1996)
• Activation ß-endorphin: social, emotional, orphysical pain/ emotionally or physicallypositive experiences (Bresin & Gordon, 2013 for an
overview)
• Can disturbance in β-endorphin be related toNSSI ?
NSSI
pain
EOS
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Biosampling procedure
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EMA-Study –Interpersonal Findings
Before I self-harmed/since the last prompt, someone Total number % of NSSI prompts
Negative events
… criticised me 13 10.1 %
… rejected/ excluded me 19 14.7%
… ignored my needs or feelings 24 18.6%
… behaved angry or aggressive towards me 14 10.9%
… let me down/ disappointed me 23 17.8%
… none of the above 90 69.8%
Positive events
… suported/ helped me 3 2.3%
… showed me affection 10 7.8%
… respected my needs or feelings 6 4.7%
… gave me their attention or time 18 14.0%
… was interested in me, understood me 12 9.3%
… none of the above 110 85.3%
Stoerkel et al., in preparation
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Hyp. 1: Negative interpersoal events predict higher probability
of NSSI events.
Hyp. 2: NSSI reduces probability of negative social events
(negative social reinforcement).
Hyp. 3: NSSI increases probability of positive social events
(positive social reinforcement).
EMA-Study –Interpersonal Findings
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Borderline PD PTSD
Major Depression
Meta-analysis of regions with positive (red)
and negative (blue) response to emotional
stimuli (significant with correction)
Schulze et al. 2019
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Emotion dysregulation
Overview
Social Interaction Pain Processing
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Pain sensitivity andStress in BPD
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measure date
su
bje
kti
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ain
perc
ep
tio
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Control
(n=19)
BPD-Baseline
(n=12)
BPD-stressed
(n=12)
Bohus et al., Psychiatry Res 2000
Ludäscher et al., Psychiatry Res 2007
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Kaess et al. 2012 Koenig et al. 2017
Cortisol-Stressreagibility and NSSI
TSST Schmerz
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König et al. 2016
Meta-Analysis Pain sensitivity and NSSI
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Neural Pain Processing in BPD
Schmahl et al., Arch Gen Psychiatry 2006
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Emotion Regulation and Pain in BPD
Niedtfeld et al., Biol Psychiatry 2010
Picture Regulation
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Reitz et al.,
JPD 2012
Emotion regulation by incision
Reitz et al.
Br Journal Psychiatry 2015
Amygdala activity
too slow!
Emotion Regulation and Incision in BPD
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Role of Tissue Injury
Willis et al., Pain 2017
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The role of seeing blood andperspective (self/other)
Self-inflicted & no blood (n=20)
Other-inflicted & no blood (n=20)
Self-inflicted & blood(n=20)
Other-inflicted & blood(n=20)
BL1 BL2 Script Pain P1 P2 P3 P5P4 P7P6 P8 P9
~45 min
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• Reduced pain sensitivity: yes
• Reduction of stress and amygdala activity by pain stimuli: yes
• Influence of tissue injury: (no)
• Influence of seeing blood: (yes)
• Role of perspective (self/other) : ?
Self-injury and Pain –Interim Summary
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Emotion dysregulation
Overview
Pain ProcessingSocial Interaction
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Domsalla et al. 2014
Social Exclusion and BPD
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Groschwitz et al. 2016
Social Exclusion and NSSI
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Bungert et al. 2015
Social Exclusion and Pain
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Can these mechanisms be modified?
Emotion dysregulation
Pain ProcessingSocial Interaction
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Normalized heat pain thresholds in remitted BPD
Bekrater-Bodmann et al., 2015, Pain
29 current BPD19 remitted BPD22 healthy controls
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cBPD rBPD HC
Heat
pain
thre
sho
ld(°
C)
*
Pain sensitivity and Remission
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Schmerzsensitivität und Amygdala-Aktivität vor und nach DBT
Changes of pain-relatedmechansims in remission
Wilis et al., Brain Behav 2018
• No strong increase of urge for NSSI after stress induction
• No relation betweenpainfulness and stress reduction
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Schmerzsensitivität und Amygdala-Aktivität vor und nach DBT
before DBT after
Niedtfeld et al., SCAN 2017
Negative pictures + pain
before after
Changes of pain-relatedmechanims after psychotherapy
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Assessment of longitudinal changes
300 NSSV 150 HC
Genetic, endocrineand
psychophysiologicalmarkers
150
E-Treatment
150
Psychoedukation
60 HC60 NSSVfMRI:
- Emotion regulation
- Social Exclusion
30
E-Treatment30
Psychoedukation
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Summary
• NSSI is clearly related to reduced pain sensitivity
• Underlying neural mechanisms point to a dysregulation of theprefrontal-amygdala axis
• Remission and psychotherapy can change these mechanisms(back to normal)
• Better understanding of neurobiological correlates of NSSI helpsto de-stigmatize behavior and improve psychotherapy
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Thanks to coworkers, collaborators and funders
06.11.2019
Dr. Inga
NiedtfeldDr. Johanna
Hepp
Dr. Alexander
Karabatsiakis and his lab
University of Ulm
Central Institute of Mental Health, Mannheim
Lisa
Stoerkel