COMMENTARY

Agitated Patients? They May Be Taking Their Cue From You

Derick E. Vergne, MD; Sivan Mauer, MD, MS; Kristina Gaud, MD

Disclosures

August 24, 2016

In This Article

Affect Regulation: A Biological Perspective

The end result of all therapeutic interventions involving intersubjective analysis of transference is affect regulation.[9] Affect regulation (also called "emotion regulation") is the capacity of an individual to modulate his or her emotional state or tone in order to adapt to the demands of the environment.[10] Affect regulation involves the effective coupling of neocortical areas to deeper or more caudal subcortical brain regions.[6]

Why is this important? The object of therapeutic relief is to tame fear. When it takes the form of a chronically unopposed stress response, fear produces chronic anxiety. In the case of trauma, chronic anxiety translates into hyperarousal (increased startle response, insomnia, and hypervigilance), and is also at the core of the dramatic affective reactivity seen in severe personality disorders, such as borderline personality disorder.[11]

The prototypical severe personality disorder, borderline personality disorder is understood to involve the hyperreactivity of the amygdala, the brain's fear center, to external stressors. A relatively stable affect depends on an efficient coupling between frontal neocortical regions, or "the thinking brain," and the lower, more primitive limbic subcortical regions.[12] In other words, there needs to be a balance between fear and its cognitive reappraisal that makes it adaptive for the organism.

In fact, the extreme emotional lability/reactivity and impulsivity that characterizes severe borderline personality disorder has been correlated with inefficient coupling between the amygdala and prefrontal cortical regions.[13] This is a critical point, because unopposed amygdala hyperreactivity without the appropriate counterbalanced activity of the "thinking brain" will induce a state of panic in mammals, including humans, that will lead to an expression of fear (affective lability) and poorly thought-out strategies for problem-solving.[14]

Evolution has provided the cognitive ability to grant context to fearful stimuli so that judgment can be exerted regarding whether a particular environmental situation is dangerous or to be feared.[15,16] Something needs to guide amygdala activity so that fear can be directed toward maximization of survival and prosperity—which in this case are the brain structures of the frontal lobes, in particular the right hemisphere prefrontal regions. The areas add context to emotion and fear, as well as abstraction and conceptual understanding, both cognitive processes that allow for executive control and contextualization of emotional/fear drives.[17] This is a critical cognitive ability that, when inefficient, is at the core of many neuropsychiatric illnesses, from posttraumatic stress disorder to personality disorders.[18]

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