Borderline personality disorder is far more common than has been previously recognized, with a prevalence rate as high as 5. The disorder has high morbidity and mortality: these patients have higher rates of suicide and poor functioning and utilize more mental health resources than most patients with axis I diagnoses 2. Psychotherapeutic treatments for borderline personality disorder typically show partial efficacy, and while patients may respond to medications in a circumscribed and often transient manner, there are currently no pharmacologic treatments for borderline personality disorder approved by the Food and Drug Administration.
Patients are, therefore, left without the benefit of reliable and effective therapies. Furthermore, pharmacotherapeutic and neurobiological research that might inform treatment in borderline personality disorder has made less progress than one would hope, especially considering the seriousness and pervasiveness of the disorder.
The article in the current issue by Prossin and colleagues 3 holds promise for helping to move the field forward. They present evidence that patients with borderline personality disorder suffer from a definitive abnormality in opioid activity. While there has been a great deal of interest in the opioid system in borderline personality disorder 4 , until this study, the role of opioids in borderline personality disorder was largely theoretical with little empirical support.
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The participants were female patients with borderline personality disorder and matched healthy comparison subjects. The results also seems to suggest that enhancement of endogenous opioid availability during sad mood is greater in patients with borderlinepersonality disorder than in healthy subjects, which might reflect a compensatory response and is consistent with lower levels of endogenous opioids in self-injurers 5.
Opioid-Deficit Model How might abnormal opioid activity help to explain the symptoms and etiology of borderline personality disorder? For decades, researchers have theorized that at least one behavior common in borderline personality disorder—self-cutting—relates to abnormalities in opioid activity. It has long been noted that patients with borderline personality disorder report that they engage in self-cutting not as a suicidal act but, rather, as a means to relieve psychic pain.
Many patients report that they do not feel physical pain at the moment when they cut themselves; instead, cutting engenders feelings of relief or well-being. One view of cutting in borderline personality disorder is that it represents a method of endogenous opioid generation. In this view, patients learn to cut themselves, thereby releasing opioids, which reward their behavior.
This, coupled with evidence that patients with borderline personality disorder who do not cut themselves are less symptomatic than those who do, led to efforts to treat borderline personality disorder with opiate antagonists by eliminating the positive feedback from cutting.
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While we know of no large-scale randomized, controlled trial, pilot studies on the efficacy of opiate antagonists showed mixed results reviewed in reference 4 and overall showed that while opiate antagonists may slightly decrease cutting behavior, they do not improve the intrapsychic distress that leads to the cutting 6. This lack of diminished distress is consistent with the model of opioid deficiency.
Thus, a promising way of construing cutting behavior in borderline personality disorder is to consider that these patients may have a preexisting deficit in endogenous opioids. According to this view, patients are self-medicating by cutting themselves, attempting to attenuate severe intrapsychic distress that healthy individuals—without such a deficit—would not be experiencing.
A deficit in opioids is also consistent with the high rate of opiate abuse in borderline personality disorder, as patients may be compensating for a deficit in endogenous opioids. Not only is there is a high rate of opiate abuse in borderline personality disorder, but there is also a high rate of borderline personality disorder among patients seeking substance abuse treatment; for instance, Clinically, it has been noted that individuals with borderline personality disorder who are taking opiates report feeling euthymic rather than euphoric, while withdrawal is associated with sustained dysphoria.
An opioid-deficit theory of borderline personality disorder might explain far more than the self-injurious behavior of these patients. For example, their extraordinary difficulties in social behavior may also be linked to a preexisting deficit in endogenous opioids. The endogenous opioid system not only regulates pain but also has an important role in social behavior.
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Reductions in its function have been associated with attachment behavior deficits and anxiety-like responses in animal models. In many species, the soothing and comforting that infants receive from maternal grooming and touching is mediated through the opioid system 8. In human beings, opioids are involved in normal and pathological emotion regulation 9 in addition to their more traditional role in modulating the sensory and affective dimensions of pain In short, there is reason to think that endogenous opioids facilitate normal social function in healthy individuals.
If the proposed model is accurate, then a deficit in endogenous opioids might go some way toward explaining not only cutting behavior and substance abuse in borderline personality disorder but also the almost ubiquitous social dysfunction observed inthis condition. Mood shifts and self-destructive behaviors in borderline personality disorder seem to arise specifically in response to interpersonal triggers Furthermore, the domains of intrapsychic pain and interpersonal dysfunction in borderline personality disorder are closely linked.
Clinical Implications The findings of Prossin and colleagues have both broad and specific clinical implications. This view could provide a heuristic model to help patients and clinicians understand the social disruption in borderline personality disorder. The satisfaction that normally accompanies closeness to other people both in early attachment and throughout life may elude patients with borderline personality disorder. If these individuals do not have sufficient endogenous opioids, then the continual craving for relationships and heightened reaction to their loss is understandable.
Such a model could provide a better understanding and improve management of disappointment in relationships for patients. It might also destigmatize the disorder; the difficulty in forming a therapeutic alliance, for example, could be reconstrued as the result of an opioid deficit. References 1. J Clin Psychiatry ; — 2. Compr Psychiatry ; — 3. Am J Psychiatry ; — 4. Stanley B, Siever LJ: The interpersonal dimension of borderline personality disorder: toward a neuropeptide model.
Am J Psychiatry ; —39 5. J Affect Disord ; — 6. World J Biol Psychiatry ; 11 2, part 2 — 7. Int J Psychiatry Med ; — 8. Neurosci Biobehav Rev ; — 9. Arch Gen Psychiatry ; — Science ; — Gunderson JG: Disturbed relationships as a phenotype for borderline personality disorder commentary. Am J Psychiatry ; — The agency told Medscape Medical News the risk evaluation and mitigation strategies, known as REMS, are scheduled to be approved in , with roll out and implementation to follow. Most committee members agreed that safety measures for opioids are urgently needed but voiced concern that the current approach does not go far enough to protect the public.
According to some reports, there are more deaths from opioid overdoses than from heroin and cocaine overdoses combined. Herbert Neuman, MD, vice president of medical affairs and chief medical officer at Covidien Pharmaceuticals, says he is eagerly awaiting the new plan. Neuman said during an interview, adding that he looks forward to the clarity a final decision will afford. The plan will alter the prescribing landscape for opioid therapies and is expected to have important implications for an estimated 4 million patients. Advisory committee members recommended mandatory training for prescribers.
They called on Congress to initiate new legislation to link physician education to the existing Drug Enforcement Administration registration system. More than 1 million clinicians are currently registered to prescribe opioids. The committee, led by Jeffrey Kirsch, MD, from the Oregon Health and Science University in Portland, argued that the overwhelming public health problem of opioid misuse is in part beyond the regulatory control of the FDA and will require a multidisciplinary approach.
Fine points out that in the absence of a well-designed uniform curriculum focused on opioid therapies in medical schools, continuing education is necessary. The advisory committee called on regulators to add immediate-release drugs to the current plan, which presently includes only extended-release and long-acting formulations.
If only schedule II compounds have more stringent requirements, then physicians may opt out by prescribing less-monitored alternatives. Fine says this is not surprising. Prior studies have yielded conflicting results regarding gender-specific differences in the quality and incidence of pain, as well as the risk factors that predict medication misuse. To further elucidate the relationship between sex and opioid misuse, Dr. Jamison and several colleagues recruited male and female patients with chronic noncancer pain who were treated at pain management centers in five states.
At study outset and completion, urine samples from of the patients were tested for both prescribed and nonprescribed substances. Multiple regression analyses identified significant correlations between specific questionnaire responses and actual opioid misuse, and controlled for possible intervening variables.
Jamison and his team found women who misused opioids had significantly higher ratings on five particular SOAPP-R items, indicating they felt overwhelmed, had been engaging in arguments or experiencing hurt, were impatient with their physician, had been sexually abused, and were concerned about how they were judged by others. In contrast, men who misused opioids had significantly higher scores on SOAPP-R items indicating a history of arrest, a bad temper, and having friends with alcohol or drug use problems.
Although the findings indicate important gender-specific risk factors for opioid misuse, Dr. Jamison cautioned that because the study population was older, mostly disabled and had a long duration of pain, these results should not be extrapolated to younger, better-functioning patients with recent-onset pain. Nevertheless, he said, the results should help clinicians discern those patients at highest risk for opioid misuse.
Shurman told Pain Medicine News. Researchers say ayahuasca, found in the Peruvian rainforest, could be used for a variety of ailments. New research suggests ayahuasca, a jungle vine found in the Peruvian rainforest, can have a powerful effect on the human central nervous system when brewed with other plants.
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Ayahuasca is one traditional plant-based medicine that has drawn the attention of investigators. In the South American jungles, it is used in religious ceremonies to induce visions and also as a remedy to cure ills. At the Onanyan Shobo spiritual retreat center in the rainforest near Iquitos, Peru, shaman Alfredo Kayruna Canayo shows off a section of the twisting, leafy vine.
Ayahuasca is known as a master plant, a very powerful remedy that treats the whole person: body, mind, and soul. What is the bad energy?
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One of them could be the fears, then some wound or injury you have. Whether the plant is being used for religious or medicinal purposes, ayahuasca is taken only in a ceremonial setting under the direction of an experienced shaman.
To turn it into a drink, also called ayahuasca, pieces of the vine are pounded into a pulp and combined with several other plants, then brewed down for eight or more hours into a thick orange liquid. That combination, shaman Alfredo says, is critical. In Shipibo culture, they believe the chacruna is the wife of ayahuasca because they help and work together.
An international research team is investigating the pharmaceutical potential of ayahuasca, known scientifically as Banisteriopsis caapi. Principal investigator, Dr.
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His team has done a chemical analysis of the medicinal drink. Pieces of the vine are pounded into a pulp and combined with several other plants, then brewed down for eight or more hours into a thick orange liquid. Ayahuasca is generally a decoction of two plants.