How could the development of personality disorders and their neuronal basis be explained

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Many of our neuronal networks are constructed from birth by the repetitive use of cognition and emotion. They differ in complexity depending on the variety of different pathways in use. Optimal stimulation enhances the spectrum of possible reactions, and mechanisms like kindling facilitate the reactive choices. If there are severe limitations of the capacity or function of neuronal connectivity, the person will not always be able to respond appropriately to differentiated situational demands. Instead, they will repeatedly rely on use of available standard reaction types. Such stereotype reactions, provoked due to limitations in limbic connectivity could be the organic basis of personality disorders.

Various factors could lead to such limitations. One may be a temporal lobe epilepsy itself, which provokes intermittent overexcitations within limbic structures, with the result of a disturbance in processing emotional reactions. It may perhaps lead to sudden unexplained experiences of fear. The seizure-induced kindling process of fear may then, as a generalizing reaction, facilitate avoidant behaviour and lead to an avoidant personality. The same behaviour strategy could develop as a reaction to punishment-induced fear, or it could be a consequence of feelings of inferiority in social communication due to severe memory deficits, etc. In any of these cases, each single behaviour of the avoidant strategy - however strange it may seem - is selected as the most adaptive of the available alternative reactions, which are reduced due to functional or structural limbic deficits. For that reason the persons themselves will not understand that their behaviour is judged as inconvenient or even as a psychiatric disorder.

Beyond the problem of maladaptive behaviour itself, personality disorders involve a reduced stress tolerance and a heightened psychic vulnerability, as an additional result of the limitations due to dysfunctional neuronal connections. Thus it becomes evident that in so-called 'stressful life events' processing capacities are easily overwhelmed and the mental system breaks down, which often results in psychotic decompensations.

For epilepsy patients with personality disorders, the context of surgery itself is a stressful event. This may facilitate neuronal excitation in unusual directions. In addition, and supporting the escalating process, the surgical disconnection of temporal structures forces other parts of the brain to take over functions during the time of scarring and healing. Thus the postoperative period is a double delicate time-span, involving changes in the cerebral mechanisms of excitation and inhibition.

Such a model of interaction of psychosocial and neurobiological factors could be paradigmatic for the development of all psychoses: maladaptive schemata of action and behaviour, acquired by constitutional and/or experiential faults, are preconditions, which emerge as personality disorders. Under special emotional stress conditions they easily run into overstimulation, become dysfunctional and end up in psychotic confusion.

According to this model personality disorders change their status from a category of psychiatric diagnosis to meaningful developmental tracks. This may lead to a better understanding of the very special views and values of these patients.

CASE REPORT

A 40-year-old woman, whose husband has a going concern with the sale of cars, and who has two children aged 20 and 8, exhibits friendly manners without obvious problems in the neurological examination. She seems a bit worried especially when in contact with the nurses.

After two seizures at the age of two, epilepsy started at 16, and worsened after her first pregnancy. She has about 6-8 seizures per month in two clusters about the time of ovulation and menstruation. The aura contains massive fear of dying. A right mesio-temporal sclerosis was diagnosed and she was operated on with an optimal prognosis. In fact she became seizure-free, except for some auras (Engel-classification: class I, category B).

Now to the postoperative psychiatric situation: she had a severe major depression starting shortly after surgery. The use of antidepressants was limited because she refused to take them after only a few days. She had massive feelings of disgust concerning her husband. About half a year after surgery she recovered from her depression, but then started to throw all conventions overboard and showed manic symptoms. Within the following months she developed the delusional idea of having a love-affair with a neurologist at our centre. She went from manic symptoms to paranoid-hallucinatory experiences of being influenced through the internet in her thoughts and emotions. She left her home and was recently hospitalized against her will and put on neuroleptic drugs.

Where are the hints from her biography?

She was raised by her mother under poor social conditions with the message: we are poor but proud. Her mother then married again and the girl suddenly was confronted with an aggressive alcoholic stepfather, who had no appreciation for her self-confidence and broke her will. This was when she started to have seizures, which were accompanied by auras of massive fear. She left her home with an unstable conception of the world and immediately became pregnant and married. At that time she had a nervous breakdown and became a psychiatric inpatient. From then on, shortly after the start of her married life, she tried to hide her inner world and to fulfil the demands of a good housewife, showing a well-functioning smiling face to her husband. She also tried to hide her seizures and told people that she suffered from circulatory lability. She suspected neighbours envied her success and invested much energy in fulfilling their imagined expectations. She blamed herself for being uncontrolled and aggressive towards her children.

Her expectations about the time after surgery were those of definitely getting the chance to be what she always believed she really was: strong, beautiful, self-confident, the way she had felt before the traumatizing experience with her stepfather.

Wasn't it predictable that the adjustment of her self-confidence would be difficult and that an overestimation of her own personal capacities could result, when the combined seizure-induced and trauma-induced neuronal pathways of fear and caution were disconnected? That the surgical-induced imbalance of excitation and inhibition could lead to uncontrolled emotional discharges in her case, which had been bundled in the seizure activity before?

Couldn't we have foreseen that she would get into trouble with her husband, when she was seizure-free? That she would search for a dreamlike man who takes care of her and that this picture could easily be projected to the neurologist who set her free of seizures, which symbolized the negative time of her life?

Wasn't it predictable that she would try to free herself from barriers and flee from home, and that she had no real chance to escape except into psychiatry? All this happened.

Maybe we could have saved her from at least some of these traps, if we had invested more time analysing the case-history before surgery and insisted on more transparency of her developmental needs, such as the narcissistic feeding by her mother, the unexpected traumatization by the stepfather with the consequence of starting epilepsy and a global distrust and suspicion against men, and later against everybody. Instead we only diagnosed her combined narcissistic and partly paranoid personality disorder and recommended psychotherapy, which did not happen.

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