Dissociation proneness and pain hyposensitivity in current and remitted borderline personality disorder

The best available evidence for psychopharmacologic treatment of borderline personality disorder (BPD) is outlined here. BPD is defined by disturbances in identity and interpersonal functioning, and patients report potential medication treatment targets such as impulsivity, aggression, transient psychotic and dissociative symptoms, and refractory affective instability Few randomized controlled trials of psychopharmacological treatments for BPD have been published recently, although multiple reviews have converged on the effectiveness of specific anticonvulsants, atypical antipsychotic agents, and omega-3 fatty acid supplementation. Stronger evidence exists for medication providing significant improvements in impulsive aggression than in affective or other interpersonal symptoms. Future research strategies will focus on the potential role of neuropeptide agents and medications with greater specificity for 2A serotonin receptors, as well as optimizing concomitant implementation of evidence-based psychotherapy and psychopharmacology, in order to improve BPD patients' overall functioning.

It is neurophysiologically and neurobiologically verified that the central nociceptive system can undergo changes and become hyperexcitable. Hyperexcitability involves wind-up (exaggerated responses) of dorsal horn neurones which in humans can be studied (temporal summation) by electrophysiological and psychophysical reactions to repeated nociceptive stimuli. Temporal summation occurs if repeated stimuli evoke increasing pain reactions. Human experimental models are adequate to investigate basic aspects and pharmacological modulation of summation and to bridge the gap between basic and clinical sciences facilitating the transfer of knowledge from basic science into the clinic. Human experimental investigations have confirmed animal studies that show that central summation is a potent mechanism in both normal and pathophysiological (hyperexcitable) conditions. Central summation should be considered as a target for the development of new centrally acting analgesics, for designing management regimens to treat intractable pain, and as a possible way of inhibiting surgically-induced afferent barrage from reaching brain centres (subconscious pain) during anaesthesia.

A psychophysiologic method previously validated in Vietnam veterans was used to evaluate the responses of medication-free Israeli posttraumatic stress disorder (PTSD) patients to script-driven imagery, before and after treatment with systematic desensitization. Skin conductance, heart rate, and frontalis EMG responses during imagery of traumatic events were assessed in three unmedicated Israeli PTSD patients. The t test of significance was used to compare the magnitude of the response to traumatic imagery with that of responses to imagery of nine other events. The elevated physiologic responses to traumatic imagery, observed before treatment, normalized after systematic desensitization. Imagery of traumata that were not treated by desensitization continued to produce elevated responses. Physiologic response during traumatic imagery may be useful in the evaluation of differential treatment outcome in PTSD.