TABLE 3. Statistical Analysis of comparison of Basal Spect vs. NeuroSpect during the
Wisconsin test.
Demonstrates maximum statistical
significance in the anterior Cyngulate Gyrus (Area 24) in both hemispheres,
followed by subgenual area (Area 25), area 40 and area 32 in the left
hemisphere and area 28 in the right hemisphere. We observe abnormality in area
28 and area 36 in the left hemisphere, area M and area 44 in both
hemispheres, and area 32, 9 and 46 Brodmann in the right hemisphere.
Paradoxical cerebral
hypoperfusion induced by Wisconsin Test in Borderline Personality Disorder Patients
Areas of Brodman with
Statistical Significance.
FIGURE 4. Statistical Analysis of Basal Vs.
Wisconsin Activated NeuroSPECT.
Demonstrates
maximal statistical significance in Anterior Cyngulate Gyrus ( Area 24) in both
hemispheres followed by subgenual area (Area 25), Area 40 and 32 in the left hemisphere
and Area 28 in Right hemisphere. These are followed by area 28 and 36 in left hemisphere,
area M* and Area 44 in both hemispheres and areas 32, 9 and 46 in right hemisphere.
*Area M corresponds to the rostral image of the dorso-lateral prefrontal cortex
ANALYSIS OF
LOCALIZATION OF RESULTS OF HYPOPERFUSION INDUCED BY WISCOSIN TEST
Table 3 and Figure 4 depict the
most significant Brodmann areas affected by hypoperfusion induced by the Wiscosin Card
Sorting Test. The areas of maximal significant differences between activation and basal
studies are listed in decreasing order: left anterior cyngulate gyrus P<0.00005 and
right cyngulate gyrus P<0.0003. These areas are followed in importance by subgenual
area, area 25 (P<0.006), area 40 (P<0.005), area 32 (P<0.006) in the right
hemisphere and area 28 (P<0.05) in the right hemisphere. Furthermore, these are
followed by area 28 (P<0.02) and area 36 (P<0.05) in the left hemisphere, area M
(P<0.042) in the left hemisphere and P<0.033 in the right hemisphere. Area 44 in the
left hemisphere has a (P<0.013) and in the right hemisphere, (P<0.016) and areas 32
(P>0.031), 9 (P<0.016) and 46 (P<0.046) in the right hemisphere.
INTERPRETATION AND
SIGNIFICANCE OF RESULTS:
AREA M
Area M corresponds to the
anterior projection of the prefrontal dorsolateral area, that is related to superior
intelligence. Intelligence in accordance to Wechsler, is the total capacity, global and
aggregated (because it corresponds to the products of different capabilities), in order to
think rationally, to behave with a purpose and cope effectively with the environment.
Normally this area is stimulated
by activation by means of the Wisconsin test and in this study, however it demonstrates a
diminution of cerebral perfusion in the Spect gathered during activation compared with the
basal state. (P<0.033 in the right hemisphere and P<0.042 in the left
hemisphere).
One of the behavioral
characteristics described in patients with borderline personality disorders is variability
in situations of fear, social performance, occupational or personal relations performance.
These disruptive conducts are associated with frustration of the patient with regards to
personal events or external events, sometimes of insignificant importance that lead
however to a pattern full of disadaptative situations. This fact is observed also in
patients with high intellectual quotient that loses their bearings at moments of crisis.
For O. Kernberg, the patient "derails" (8).
Another difficulty of borderline
patients is the incapability to assign hierarchy in daily life: this implies a correct
perception of emotional detail and a definition of importance within a global activity. In
periods of stress in which affectivity is interfered, the responsiveness is less
predictable. This difficulty to evaluate the significance of the emotional weight on
adaptation is more severe and permanent in schizophrenia. In a similar manner to patients
with borderline personality disorder and schizophrenia the dorso-lateral prefrontal area
diminishes paradoxically its cerebral perfusion during the Wisconsin card sorting test
(21).
It is stated in the DSM-IV that
borderline patients improve their behavior on or about 40 years of age and before that
time they present with a blockade to change, which is difficult to break (difficulty to
make their behavior more flexible or keep stable patterns of behavior DSM-IV). One of the
reasons for consultation to the psychiatrist is the appearance of a crisis, like it
occurred in all patients studied in this group; at this time the circuit that is being
studied is dysfunctional. One could therefore deduct that there is a weak remembrance of
remote or recent information, particularly of situations that are harming the patient
again, and for this reason we can state that these patients do not learn from experience.
Ana Freud (22) would say that in this condition there are defense mechanisms in action
like negation or intellectualization. However, Gazzaniga (11) would remind us that human
beings have a 98% of our perceptions in an automatic way where the left hemisphere is
ready to explain the facts from its limited angle of observation that is influenced by
false registers in memory.
Another characteristic of the
performance of these patients is related to the use of psychotropic drugs where the
dysfunction of the dorso lateral prefrontal area has been described and there is a more
evident conduct of utilization of information from the environment and imitation. Both
types of conduct can be adaptable to normal subjects such as consumerism due to imitation
or the following of the dictates of fashion, however, in borderline patients this is
expressed in compulsive buying, excessive gambling, sexual promiscuity and consumption of
psychotropic drugs.
For Gazzaniga, memory keeps
records that are influenced by the emotional circumstances at the time of codification.
Furthermore, in front of new events the brain processes them comparing with events that
were recorded previously.
It is of note to consider the
pioneering vision of Freud, that refers to this condition as perception recharging the
mnesic prints that would acquire therefore significantly an individual characteristic.
Both investigations coincide with the fact that these patients have a difficulty to change
opinions or make their judgements more flexible with respect to the perceived stimuli.
This condition is very evident in the borderline patients with a manifestation of
characteristic of rigid and polarized attitude in their affective relationships,. with
regards to the dependency of overvaluing or devaluing from one extreme to another
(DSM-IV). This phenomenon has a tendency to diminish in significance after 45 years of
age. At this age the right hemisphere begins to acquire a preponderance of importance that
is reflected by more common sense (as we understand by this the capability to detect
social clues and environmental clues and to respond adaptively to them) and also a major
capacity to structure in a globality. It is necessary to emphasize that all that is
described corresponds functionally to the dorso lateral prefrontal circuit.
The conducts of utilization of
environment and imitation that are clearly noted in the item of DSM-IV refer to the
"loss of control" in different areas that are potentially harmful such as
gambling, drugs, careless driving, consumption of psychotropic drugs and abnormalities of
appetite.
Finally in this circuit we
localize capabilities to perform complex areas of attention, to guide conduct with a
structured thought, all these tasks of complex attention and the guidance of a conduct
like thinking, all of which that are frequently impaired in patients with borderline
personality disorders.
Area 24
It corresponds to the
anterior cyngulate gyrus and demonstrates in the studies a diminution of cerebral blood
flow (P<0.0003 in the right hemisphere and P<0.00005 in the left
hemisphere). This circuit begins in area 24 of Brodmann and its dysfunction can be
expressed with demotivation (24). Furthermore, its clinical manifestations are expressed
with episodic mutism and marked apathy as a response to demands of changes (DSM-IV).
Furthermore the feeling of psychic "vacuum" could precede more impulsive acts
(25). The indifference to physical pain in self-damaging acts is a situation that is
frequently observed in these patients. It is important to remember the richness of opiate
receptors and immunoreactive encephaline in this area (26).
Area 32
In the left hemisphere, there
is a significant diminution of perfusion during activation with the Wisconsin test P<0.006
that becomes P<0.031 in the right hemisphere. This area belongs to the
limbic system and precedes anatomically the anterior cyngulate gyrus. It is an efferent
target of the orbito-frontal cortex, that is related to mood disorder (27, 28).
The limbic system has a
significant importance in areas of learning and we are aware of the interrelation of
cognition and emotion (29).
Area 28
This area is located in the
medial temporal cortex which corresponds to the entorhinal and perirhinal cortex (30).
This area shows a significant
difference with diminution during activation P<0.02 at the left and P<0.05
at the right and is related to emotional and neurovegetative situations and is
accompanied in borderline patients with anxiety, with symptoms in the abdominal, thoracic
region or in areas of visceral content.
Furthermore, this area is rich in
connections with the hippocampus structure that appears to be a site of temporal memory,
this temporal memory later on transfers to other areas of the cortex for permanent
recording (31). Probably this storage is performed in a holonomic modality (32), which
allows the retrieval from any detail of the totality of information.
The mnesic details have clearly
an effective component in areas 28 that is closely related to the orbito frontal
subcortical circuit, which is related to mood and other characteristics of personality and
it becomes an important input in this sense.
Area 36
The left hemisphere which
shows a clear diminution of blood flow during activation with P<0.05 it is less
significant than the previously described areas and it has connections with area 28.
Area 40
The statistical significance
of the findings concerning this area have a P<0.005 at the left and P<0.04
in the right.
There is a close correlation of
this area with the memory of speech. Its function is shared with areas 9, 44, 39, 46, 47,
that show a significant change in this study.
Area 25
There is significance only in
the left hemisphere P<0.006. This area is located in the "Genus
angularis", subgenus area of the Corpus Callosus. It has been studied by Damasio and
others (33) because of its important relation with the capacity of enjoying with
performance and with positive anticipation to future facts or optimism, both functions
therefore related to the capacity of finding a meaning to existence.
This area has been defined as the
critical locus in Major Depression. In this condition there is a diminution of cerebral
blood flow and metabolism and also in MRI there is a diminution of the volume of gray
matter of this structure.
It is probable that in borderline
patients this same finding is accompanied by dysthymias.
Area 44
Both appear significantly
diminished during activation P<0.016 in the right hemisphere and P<0.013 in
the left hemisphere. This area together with areas 9, 40, 39, 46 and 47 participate in
verbal memory.
Area 9
Together with area 8 of
Brodmann corresponds to the dorso lateral prefrontal cortex in a lateral and medial image,
for this reason the observations that we made for area M are equally applicable: in the
right hemisphere P<0.016.
Summary
| Introduction | Method | Results | Discussion | References | Complete Version | Article Home |
