Microstructural white matter alterations in borderline personality disorder: A minireview

Neurobiological correlates of personality dimensions in borderline personality disorder using graph analysis of functional connectivity

Borderline personality disorder (BPD) is is a type B personality disorder primarily characterized by a pattern of unstable interpersonal relationships, a distorted self-concept, and intense emotional reactions, associated with extreme and opposing mental and behavioral states, which coexist and lead to destructive behaviors such as self-harm, commonly recurring over time.. The Personality Inventory for the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition (PID-5) provides a dimensional assessment of maladaptive domains associated with personality disorders, improving the understanding of their complex clinical presentations. While altered brain functional connectivity (FC) has been reported in BPD, neurobiological-clinical correlations remain debated. This study explores the relationship between the personality dimensions of BPD and resting-state fMRI (rs-fMRI) FC. Twenty-eight patients with BPD (6M/22F, 23.7 ± 3.4 years) and twenty-eight matched healthy controls (6M/22F, 24.3 ± 2.8 years) underwent a psychiatric assessment, including the PID-5, and an MRI protocol including rs-fMRI. Functional data were analyzed via graph theory to derive network properties at global and nodal levels, which were correlated with the PID-5 subdomains. The results revealed impairments across all personality trait facets. Patients had lower global connectivity and compromised centrality of several limbic structures and frontotemporal regions. Significant correlations were found between separation insecurity and global efficiency (R = 0.60, adjusted-p = 0.035) and between depressivity and the degree of the left middle temporal gyrus (R = 0.69, adjusted-p = 0.023) in females. These findings suggest links between negative affectivity traits, in particular separation insecurity and depressivity, and specific brain network dysfunctions in BPD.

White matter changes in paediatric bipolar disorder: A systematic review of diffusion magnetic resonance imaging studiesA systematic review of diffusion magnetic resonance imaging studies

BACKGROUND

Paediatric bipolar disorder (PBD) is characterized by severe mood fluctuations that deviate from typical childhood emotional development. Despite the efforts, the pathophysiology of this disorder is not well understood yet. In this review, we aimed to synthesize existing diffusion magnetic resonance imaging (dMRI) research findings in PBD.

METHODS

A literature search was conducted using PubMed, Embase, Scopus, and Web of Science databases to identify relevant studies published before April 2024.

RESULTS

A total of 23 studies were included in the review. The findings showed variations of fractional anisotropy (FA), axial diffusivity, radial diffusivity, and apparent diffusion coefficient in PBD compared to healthy controls (HCs). Key findings included decreased FA in the anterior cingulate, anterior corona radiata, and corpus callosum, particularly the genu, which correlated with clinical symptoms. Furthermore, longitudinal studies emphasized the significance of the uncinate fasciculus as having atypical developmental trajectories in PBD compared to HCs. In addition, graph analysis revealed widespread changes in structural connectivity, especially affecting the orbitofrontal cortex, frontal gyrus, and basal ganglia. Lastly, machine learning models showed promising results in differentiating PBD from HCs.

LIMITATIONS

Cross-sectional design of the studies, small sample sizes, and different imaging protocols preclude integration of the findings.

CONCLUSION

PBD seems to be associated with widespread structural changes compared to HC. Understanding these changes, which might account for the clinical manifestations of this disorder, increase our knowledge of the neurobiological underpinnings of PBD. This, in turn, may help develop more effective treatments for this disorder.

Effect of metacognitive interpersonal therapy on brain structural connectivity in borderline personality disorder: Results from the CLIMAMITHE randomized clinical trial

BACKGROUND

Recently, we showed that Metacognitive Interpersonal Therapy (MIT) is effective in improving clinical symptoms in borderline personality disorder (BPD). Here, we investigated whether the effect of MIT on clinical features is associated to microstructural changes in brain circuits supporting core BPD symptoms.

METHODS

Forty-seven BPD were randomized to MIT or structured clinical management, and underwent a clinical assessment and diffusion-weighted imaging before and after the intervention. Fractional anisotropy (FA), mean, radial, and axial diffusivities maps were computed using FSL toolbox. Microstructural changes were assessed (i) voxel-wise, with tract based spatial statistics (TBSS) and (ii) ROI-wise, in the triple network system (default mode, salience, and executive control networks). The effect of MIT on brain microstructure was assessed with paired tests using FSL PALM (voxel-wise), Linear Mixed-Effect Models or Generalized Linear Mixed Models (ROI-wise). Associations between microstructural and clinical changes were explored with linear regression (voxel-wise) and correlations (ROI-wise).

RESULTS

The voxel-wise analysis showed that MIT was associated with increased FA in the bilateral thalamic radiation and left associative tracts (p < .050, family-wise error rate corrected). At network system level, MIT increased FA and both interventions reduced AD in the executive control network (p = .05, uncorrected).

LIMITATIONS

The DTI metrics can't clarify the nature of axonal changes.

CONCLUSIONS

Our results indicate that MIT modulates brain structural connectivity in circuits related to associative and executive control functions. These microstructural changes may denote activity-dependent plasticity, possibly representing a neurobiological mechanism underlying MIT effects.

TRIAL REGISTRATION

ClinicalTrials.govNCT02370316 (https://clinicaltrials.gov/study/NCT02370316).

Diffusion tensor imaging of white-matter structural features of maltreating mothers and their associations with intergenerational chain of childhood abuse

Child abuse causes lifelong adverse outcomes for both physical and mental health, although many are resilient. Efforts to prevent this issue from the parental side require an understanding of the neurobiological basis that leads abusive parents to perpetrate abuse and the influence of the intergenerational chain of childhood abuse. Therefore, this study was conducted to compare the brain white-matter fiber structures between 11 maltreating mothers who had been recognized as having conducted child abuse prior to the intervention and 40 age-matched control mothers using tract-based spatial statistics. There was a significantly reduced axial diffusivity (AD) and a similar trend in fractional anisotropy (FA) in the right corticospinal tract in maltreating mothers compared to control mothers. Therefore, maltreating mothers may have excessive control over the forcefulness of voluntary movements. These features also decreased as the number of childhood abuse experiences increased, suggesting that an intergenerational chain of child abuse may also be involved. Other aspects observed were that the higher the current depressive symptoms, the lower the AD and FA values; however, they were not related to parental practice or empathy. These results corroborate the neurobiological features that perpetrate behaviors in abusive mothers.

Association of white matter microstructural alteration with non-suicidal self-injury behavior and visual working memory in adolescents with borderline personality disorder

BACKGROUND

Non-suicidal self-injurious behavior (NSSI) is the core characteristic of adolescent borderline personality disorder (BPD) and visual working memory is involved in the pathological processes of BPD. This study aimed to investigate alterations in white matter microstructure and their association with NSSI and visual working memory in adolescents with BPD.

METHODS

53 adolescents diagnosed with BPD and 39 healthy controls (HCs) were enrolled. White matter microstructure was assessed with the fractional anisotropy (FA) and mean diffusivity (MD) from diffusion tensor imaging (DTI). Correlation analysis was performed to assess the association between FA/MD and core features of BPD. A mediation analysis was performed to test whether the effects of white matter alterations on NSSI could be mediated by visual working memory.

RESULTS

Adolescents with BPD showed a reduced FA and an increased MD in the cortical-limbic and cortical-thalamus circuit when compared to the HCs (p < 0.05). Increased MD was positively correlated with NSSI, impulse control and identity disturbance (p < 0.05), and was negatively correlated with the score of visual reproduction. Reserved visual working memory masked the effects of white matter microstructural alterations on NSSI behavior.

CONCLUSIONS

White matter microstructural deficits in the cortical-limbic and cortical-thalamus circuits may be associated with NSSI and visual working memory in adolescents with BPD. Reserved visual working memory may protect against NSSI.

Resting-state functional magnetic resonance imaging alterations in borderline personality disorder: A systematic review

BACKGROUND

Borderline personality disorder (BPD) is a severe psychiatric disorder characterized by emotion dysregulation, impulsivity, and interpersonal disturbances. Several structural and functional neuroimaging abnormalities have been described in BPD. In particular, resting-state functional magnetic resonance imaging (rs-fMRI) studies have recently suggested various connectivity alterations within and between large-scale brain networks in BPD. This review aimed at providing an updated summary of the evidence reported by the available rs-fMRI studies in BPD individuals.

METHODS

A search on PubMed, Scopus, and Web of Science was performed to identify rs-fMRI alterations in BPD. A total of 15 studies met our inclusion criteria.

RESULTS

Overall, aberrant resting-state functional connectivity (rs-FC) within and between default mode network (DMN), salience network (SN), and central executive network (CEN) were observed in BPD compared to healthy controls, as well as selective functional impairments in bilateral amygdala, anterior and posterior cingulate cortex, hippocampus, and prefrontal cortex.

LIMITATIONS

The observational design, small sample size, prevalence of females, high rates of concurrent comorbidities and medications, and heterogeneity across imaging methodologies limit the generalizability of the results.

CONCLUSIONS

The identification of altered patterns of rs-FC within and between selective brain networks, including DMN, SN, and CEN, could further our knowledge of the clinical symptoms of BPD, and therefore, future studies with multimodal methodologies and longitudinal designs are warranted to further explore the neural correlates of this disorder.

Structural connectivity of grandiose versus vulnerable narcissism as models of social dominance and subordination

Social dominance and subordination have been linked to fronto-limbic and fronto-thalamic networks and are related to phenotypes such as grandiose vs. vulnerable narcissistic traits. The latter have been linked to clinical features such as empathy and emotional regulation. In this study we tested the hypotheses that narcissistic traits are associated with white matter integrity in fasciculus uncinate, cingulum, and anterior thalamic radiation (ATR). We applied the Pathological Narcissism Inventory (PNI) to assess narcissistic traits in a sample of 267 psychiatrically healthy individuals. We used 3 T MRI to acquire Diffusion Tensor Imaging data for analysis with TBSS in FSL applying TFCE to test for correlations of fractional anisotropy (FA) and PNI scales. We detected a significant positive correlation of PNI total and FA in the right posterior cingulum. PNI Vulnerability was significantly correlated with FA in the left anterior and right posterior cingulum. We did not find overall correlations with PNI Grandiosity, but additional analyses showed significant effects with FA of ATR. Our results strengthen network models for narcissism underlying both personality variation and pathology. Especially associations of narcissistic vulnerability within fronto-limbic tracts suggest overlaps within neural correlates of related phenotypes like neuroticism, social subordination, and negative emotionality.

Aberrant Structural Connectivity of the Triple Network System in Borderline Personality Disorder Is Associated with Behavioral Dysregulation

Background: Core symptoms of Borderline Personality Disorder (BPD) are associated to aberrant connectivity of the triple network system (salience network [SN], default mode network [DMN], executive control network [ECN]). While functional abnormalities are widely reported, structural connectivity (SC) and anatomical changes have not yet been investigated. Here, we explored the triple network’s SC, structure, and its association with BPD clinical features. Methods: A total of 60 BPD and 26 healthy controls (HC) underwent a multidomain neuropsychological and multimodal MRI (diffusion- and T1-weighted imaging) assessment. Metrics (fractional anisotropy [FA], mean diffusivity [MD], cortical thickness) were extracted from SN, DMN, ECN (triple network), and visual network (control network) using established atlases. Multivariate general linear models were conducted to assess group differences in metrics and associations with clinical features. Results: Patients showed increased MD in the anterior SN, dorsal DMN, and right ECN compared to HC. Diffusivity increases were more pronounced in patients with higher behavioral dysregulation, i.e., suicidal attempting, self-harm, and aggressiveness. No differences were detected in network structure. Conclusions: These results indicate that the triple network system is impaired in BPD at the microstructural level. The preferential involvement of anterior and right-lateralized subsystems and their clinical association suggests that these abnormalities could contribute to behavioral dysregulation.

Auditory event-related electroencephalographic potentials in borderline personality disorder

BACKGROUND

Borderline Personality Disorder (BPD) is characterized by mood dysregulation, impulsivity, identity disturbances, and a higher risk for suicide. Currently, the diagnosis is solely based on clinical observation of overt symptoms, and this can delay the detection of the disease and the timely start of appropriate treatment. Several candidate clinical tools have been studied to better characterize BPD, including event-related potentials (ERP). This review aimed at summarizing the results of the available ERP studies on BPD to clarify the possible application of this technique in the early diagnosis of BPD.

METHODS

A bibliographic search on PubMed and PsycInfo was performed in order to identify studies comprising individuals with BPD diagnosis and a control group that evaluated the ERP elicited by auditory stimuli.

RESULTS

Ten studies that explored various ERP components associated with auditory stimuli in BPD were included. Overall, the results showed that positive ERP (P50, P100, and P300) amplitude and latencies as well as loudness dependance were altered in BPD patients compared to controls, possibly reflecting deficits involving attention, mainly at its early stage, and executive functions.

LIMITATIONS

The reviewed studies used different ERP approaches and non-homogeneous BPD diagnostic criteria.

CONCLUSIONS

Auditory ERP appear to be a promising tool for the assessment of BPD patients, especially for early diagnosis and evaluation of cognitive symptoms.

Narcissistic Traits and Executive Functions

Several personality disorders have been associated with cognitive impairment, including executive functions like working memory. Yet, it is unclear whether subclinical expression in non-clinical persons is associated with cognitive functioning. Recent studies indicate that non-clinical subjects might, in fact, perform better with increasing moderate to mild expressions of narcissistic features. We tested working memory performance in a cohort of n=70 psychiatrically and neurologically healthy subjects using Wechsler Adult Intelligence Scale (WAIS/WIE) subtests Arithmetic, Digit Span and Letter-Number Sequencing, and assessed narcissistic features using three different inventories: the widely used Narcissistic Personality Inventory (NPI), as well as two clinically used measures of narcissistic traits and states, respectively, derived from schema-focused therapy, i.e., the Young Schema Questionnaire (YSQ) entitlement/grandiosity subscale and the Schema Mode Inventory (SMI) self-aggrandizer subscale. In accordance with our hypothesis, we found nominally significant positive correlations of WIE Arithmetic performance with NPI total score (Spearman's rho=0.208; p=0.043) and SMI self-aggrandizer scale (Spearman's rho=0.231; p=0.027), but findings did not survive false discovery rate (FDR) adjustment for multiple comparisons (pFDR=0.189 and pFDR=0.243, respectively). While our findings add to recent studies on cognitive performance in subclinical narcissism, they fail to demonstrate an association of cognitive performance with narcissistic traits across multiple working memory tests, indicating the need for additional study, including complementary executive functions in larger cohorts and ranges of phenotype expression.

Repetitive transcranial magnetic stimulation in patients with borderline personality disorder: A systematic review

The literature on the application of repetitive transcranial magnetic stimulation (rTMS) in Borderline Personality Disorder (BPD) is unclear, even though its neuromodulatory effects on underlying neural circuitry involved in BPD symptoms suggest that it could be a potential treatment option. We sought to review the evidence on rTMS as a treatment option in BPD. PubMed (for Medline database), Google Scholar, and Scopus were systematically searched following the PRISMA guidelines for studies of any design examining the application of the rTMS treatment in adult patients with precise and primary diagnosis of BPD written in the English language. The systematic review has been registered on PROSPERO (CRD42020215927). Forty one records were screened, and eight fulfilled inclusion criteria (total of 63 patients). The existing studies suggest that rTMS is a well-tolerated treatment in patients with BPD. Double-blind randomized controlled studies are necessary to help elucidate the effects of rTMS in the different symptoms in BPD and establish efficacy and the best cortical targets and stimulation protocols. Longitudinal studies that combine evidenced based psychotherapy with rTMS may be a future line of investigation that could potentially improve outcomes for this population.

Effects of pharmacological treatments on emotional tasks in borderline personality disorder: A review of functional magnetic resonance imaging studies

BACKGROUND

Borderline personality disorder (BPD) is a common mental disorder characterized by instability in interpersonal relationships, impaired self-image, impulsivity and aggressive behaviors that often requires pharmacological treatments. Neuroimaging alterations have been extensively reported in BPD, especially in regions within the fronto-limbic system. Although medications can be an important confounding factor in functional Magnetic Resonance Imaging (fMRI) studies, their role on brain function in BPD patients still remains uncertain. Therefore, this review aims to improve our understanding on the potential effect of the most commonly prescribed drugs for BPD on brain function during processing of emotional tasks.

METHODS

A search on PubMed, Scopus and Web of Science of fMRI studies exploring the effect of antipsychotics, antidepressants and mood stabilizers on brain activity during processing of emotional tasks on BPD was conducted.

RESULTS

Overall the studies showed small or no effect of pharmacological treatments on brain activity and connectivity in BPD patients during processing of emotional tasks.

LIMITATIONS

The small sample size, the observational design, the elevated percentage of women, the concomitant use of psychostimulants, anticholinergics and opioids substitute treatments and the high rate of comorbidities limit the conclusion of this review.

CONCLUSIONS

Pharmacological treatments seem to have minor role on brain activity/connectivity in BPD patients during emotional tasks, ultimately suggesting that in BPD patients brain deficits seem not be influenced by medications. This might be due to functional brain specificities of BPD and to the differences in pharmacological regimens and compliance to therapy between BPD and other common psychiatric disorders.

Neuropsychological deficits correlate with symptoms severity and cortical thickness in Borderline Personality Disorder

BACKGROUND

Neuropsychological abnormalities have been proposed to contribute to the development and maintenance of Borderline Personality Disorder (BPD). Previous meta-analyses and reviews confirmed deficits in a broad range of cognitive domains, including attention, cognitive flexibility, memory, executive functions, planning, information processing, and visuospatial abilities, often suggested to underlie brain abnormalities. However, no study directly explored the structural neural correlates of these deficits in BPD, also accounting for the possible confounding effect of pharmacological treatments, often used as adjunctive symptom-targeted therapy in clinical setting.

METHODS

In this study we compared the performance of 24 BPD patients to 24 healthy controls obtained at the neuropsychological battery "Brief Assessment and Cognition in Schizophrenia", exploring the relationship between the cognitive impairments and current symptomatology, brain grey matter volumes and cortical thickness, controlling for medications load.

RESULTS

Data revealed deficits in verbal memory and fluency, working memory, attention and speed of information processing and psychomotor speed and coordination when medication load was not in the model. Correcting for this variable, only the impairment in psychomotor abilities remained significant. A multiple regression confirmed the effect of this neuropsychological domain on the severity of BPD symptomatology (Borderline Evaluation of Severity Over Time). In BPD, the performance at psychomotor speed and coordination was also directly associated to cortical thickness in postcentral gyrus.

LIMITATIONS

Relatively small sample size, especially for neuroimaging.

CONCLUSIONS

Our study highlighted an influence of BPD neuropsychological impairments on symptomatology, and cortical thickness, prompting the potential clinical utility of a cognitive remediation program in BPD.

Magnetic resonance diffusion tensor imaging in psychiatry: a narrative review of its potential role in diagnosis

Diffusion tensor imaging (DTI) is an imaging technique that uses magnetic resonance. It measures the diffusion of water molecules in tissues, which can occur either without restriction (i.e., in an isotropic manner) or limited by some obstacles, such as cell membranes (i.e., in an anisotropic manner). Diffusion is most often measured in terms of, inter alia, fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD). DTI allows us to reconstruct, visualize, and evaluate certain qualities of white matter. To date, many studies have sought to associate various changes in the distribution of diffusion within the brain with mental diseases and disorders. A better understanding of white matter integrity disorders can help us recognize the causes of diseases, as well as help create objective methods of psychiatric diagnosis, identify biomarkers of mental illness, and improve pharmacotherapy. The aim of this work is to present the characteristics of DTI as well as current research on its use in schizophrenia, affective disorders, and other mental disorders.

How to understand and help a person with borderline personality. Case report and literature review on the therapeutic possibilities

Introduction: The study aims to present 1) a case report of an 18-year-old female patient with borderline personality disorder (BPD) 2) the diagnostic and treatment difficulties in BPD patients.

Materials and methods: The review of the literature from the years 1953-2020 searched from PubMed, Google Scholar, and Web of Science databases.

Discussion: Patient, 18-years old, hospitalized five times for psychiatric care, presenting self-injurious behaviours, hurting herself within forearms. A patient attempted suicide eight times. She is living with her divorced parents. The patient’s father has a new partner with whom he has children. The patient used marijuana and she was experiencing psychotic symptoms under its influence. She smokes 10 cigarettes per day and drinks alcohol once a week since she was 16 years old. Psychiatric problems appeared when the patient started learning in high school.

Conclusions:

1. Borderline personality disorder (BPD) is a serious psychiatric condition of a difficult diagnosis that should be differentiated with many other psychiatric disorders such as an atypical or subclinical course of psychosis, affective disorders, or dissocial personality.

2. A therapeutic process of a person with BPD is based on psychotherapy and personalized treatment strategies, whereas, pharmacological treatment plays only a supporting role during BPD treatment.