APNA 25th Annual Conference October 19, Session 1022

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1 When Words Are Not Enough The Use of Sensory Modulation Techniques to Replace Self- Injurious Behaviors in Patients with Borderline Personality Disorder General Organization of the Brain Lita Sabonis, RN, BS, BSN, PMH-BC 1 4 Disclaimer Thalamus There is no financial support for this project from any outside or commercial source. On top of brainstem Gateway to incoming Sensory Data Has extensive connection to other regions of brain 2 5 Borderline Personality Disorder (BPD) Statistics 1%-2% of general population and 15%-20% of psychiatric population 70% experience early trauma Unstable relationships, impulsive behavior, and frequently Self-Injurious Behavior (SIB) Almost all experience Suicidal Ideation 10% commit Suicide Neocortex Rests above thalamus Mediates more complex Information- Processing functions: Reasoning Perception of Abstract Representations Thinking 3 6 Sabonis 1

2 Centrally located Limbic System Includes Orbitofrontal Cortex, Anterior Cingulate, Amygdala a Coordinates activity between Higher and Lower Brain Structures Limbic System: Amygdala Lends emotional memory to a situation DOES NOT FORGET Major involvement in extreme response to minor situations 7 10 Limbic System Functions Mediates - Emotion Motivation Goal-Directed Behavior Permits - Integration of Appraisal of Meaning Processing Social Experience Regulation of Emotion Limbic System: Hippocampus Encodes episodic memory Transitions short-term term to long-term memory Provides recollection of events at will Influenced by the Amygdala 8 11 Limbic System: Anterior Cingulate The center for sorting out Conflict Best demonstrated by Stroop Test Tests how interference from different senses is resolved Limbic System: Orbitofrontal Cortex Part of the Prefrontal Cortex Sensory Integration Center for the seven senses Primarily involved in decision-making 9 12 Sabonis 2

3 Limbic System: Prefrontal Cortex Performs Executive Functions Decides correct social behavior Resonates thoughts & actions with goals Differentiates between Good & Bad, Better & Best Estimates Prediction of Outcome Maintains Social Control when urges conflict Provides top-down feedback to modulate behavior Differentiating the Brain Develops through impact of early interpersonal interactions upon genetic coding Shapes how neurons connect to form specialized circuits that produce mental processes Especially important: GENES DO NOT STAND ALONE Maturation of the Prefrontal Cortex and Behavioral Regulation Occurs In Childhood and Adolescence When the Majority of Sexual and Physical Abuse Occurs EMOTION REGULATION IS AT THE CENTER OF SELF- ORGANIZATION OF THE MIND Limbic System: Hypothalamus and Pituitary Responsible for physiological homeostasis Accomplished by neuro-endocrine endocrine hormonal release upon the Hypothalamic-Pituitary Pituitary-Adrenocortical Axis Trauma will adversely affect this system Missing Links Loss of Neural Synchrony, Lack of Emotion Regulation and Impulse Control BPD - distinct breakdowns in integration of posterior and frontal brain networks Tested ability of subjects to discriminate salient from background tones Measured magnitude and latency of peak Gamma Phase Synchrony Significant delay in subjects with BPD Conclusion- impairment and functional connectivity of neural systems underlie core dimensions of cognitive disturbance and poor impulse control Sabonis 3

4 Emotionally Controlled Decision-Making - Gene Variant Related to Serotonin Synthesis in Women BPD A subgroup with the TPH-1 gene variant, would demonstrate impaired decision making Tested with the Iowa-Gambling Test Measured degree of risk-taking exhibited by subjects Results - BPD group scored significantly below control group. TPH- 1 gene variant had significantly higher scores in Impaired Decision Making within the BPD group. WHICH PART OF THE BRAIN ARE YOU ATTEMPTING TO ENGAGE? Conclusion - significantly more risky decisions, and the TPH-1 gene variant had an even more impaired ability to make good decisions Reduced Amygdala and Hippocampus Size in Trauma- Exposed BPD Women with and Without Posttraumatic Stress Disorder Self-Injury Cycle Trauma-exposed BPD women, but without PTSD, would show reduced amygdala & hippocampus size and impaired cognition MRIs and neuropsychological testing 2 Measured amygdala and hippocampus, total brain volume, and scores on neuropsychological lt tests t Results -subjects with BPD and PTSD displayed significantly reduced amygdala and hippocampal size, and significantly impaired cognition Triggers Self-Injury Coping BPD but without PTSD showed significantly reduced amygdala and hippocampus, but had normal cognition Conclusion- small amygdala size, amygdala and hippocampal size reduction is due, not only to PTSD, but also to traumatic exposure Script-Driven Imagery of Self-Injurious Behavior Subjects with BPD would show significant differences in Orbitofrontal Cortex, Anterior Cingulate Cortex, and Dorsolateral Prefrontal Cortex Tested by presentation of script-driven imagery designed to induce emotional distress Measured activity in the above areas of the brain Results -significant decrease in activation of the Orbitofrontal Cortex and the Anterior Cingulate Cortex and an increase in activity of the Dorsolateral Prefrontal Cortex Conclusion - increased action in the Dorsolateral Prefrontal Cortex is due to the deactivation of the Orbitofrontal Cortex, and relates to failure to inhibit emotional or cognitive reactivity Decrease in the Anterior Cingulate Cortex activation results in deficits in active monitoring of situations, and decrease in pain sensitivity Visual Auditory Gustatory Olfactory Tactile Vestibular Proprioceptive Seven Senses Sabonis 4

5 Tactile Sense Account for tactile sensitivities when promoting sense of containment Stuffed animal Scratchy, tight or soft clothing Tickling, tapping Olfactory Sense Elicit positive memories Resist idea that one scent fits all Use of lotions Use of cinnamon and vanilla Idiosyncratic scents Vestibular Sense Use of Linear Vestibular Stimulation Rocking Running Bending over so the head is off center plane Jumping up and down When Words Are Not Enough Use of the Seven Senses Can Modify Input into the Amygdala and Thereby Reduce Impulses to Self-Injure Proprioceptive Sense Establish where an individual perceives herself in space Wrapping with blankets Use of shawls Use of walls Use of furniture 27 Sabonis 5