Reduced prefrontal and orbitofrontal gray matter in female adolescents with borderline personality disorder: Is it disorder specific?

Associations of Child Amygdala Development with Borderline Personality Symptoms in Adolescence

BACKGROUND

The understanding of the neural correlates of borderline personality disorder (BPD) is limited, but suggests alterations in limbic structures play a role in adult BPD. The developmental course of structural neural differences in BPD is unknown. Whether there is specificity for structural alterations in BPD compared with other psychiatric presentations, such as major depressive disorder (MDD), remains unexplored. The current study examined childhood trajectories of two limbic regions implicated in BPD, hippocampal and amygdala volume, as they relate to adolescent BPD symptoms as compared with MDD symptoms.

METHODS

Participants (N =175; 85 [48.6%] female) were from a 17-year longitudinal study of preschool depression. Participants completed up to 5 MRI scans from late childhood through adolescence. General linear models assessed the relationship between gray matter volume intercepts/slopes and BPD symptoms to understand the influence of the developmental trajectory of brain regions on BPD. Separate models assessed the relationship between MDD symptoms and volume intercepts to assess diagnostic specificity.

RESULTS

Lower childhood amygdala volume (intercept; age 13 centered) across scans was associated with higher adolescent BPD symptoms (β=-0.25, adj. p=.015). There was no relationship between the slope of amygdala volume and BPD symptoms. There was no relationship between hippocampal volume and BPD, nor any relationship between amygdala or hippocampal volume and MDD symptoms in adolescence.

CONCLUSIONS

Our findings add evidence for the role of alterations in amygdala structure in BPD development. Decreased amygdala volume as early as age 13 may be an early indicator for the development of BPD in adolescence.

Borderline personality disorder and post-traumatic stress disorder in adolescents: protocol for a comparative study of borderline personality disorder with and without comorbid post-traumatic stress disorder (BORDERSTRESS-ADO)

BACKGROUND

Borderline Personality Disorder (BPD) is a prevalent and debilitating psychiatric condition often accompanied by Post-Traumatic Stress Disorder (PTSD), with a substantial prevalence of trauma history among affected individuals. The clinical, cognitive, and cerebral parallels shared with PTSD suggest a trauma-related etiology for BPD. Studies consistently demonstrate a reduction in hippocampal volume in individuals with BPD, echoing findings in PTSD. However, the interpretation of this shared neurobiological profile remains contentious, with ongoing debates regarding the independence of these pathologies or the potential exacerbation of diminished hippocampal volume in BPD due to concurrent PTSD. Differential impacts on hippocampal subfields across both disorders may further complicate interpretation, suggesting the volume of hippocampal subfields as a potential discriminant biomarker. This study aims to characterize the multidimensional specific and shared profiles of BPD and PTSD-related alterations, with a particular emphasis on hippocampal subfields during adolescence, a crucial period in BPD development.

METHODS

This study focuses on female adolescents, who are more prevalent in the BPD population. Participants are categorized into three groups: BPD, BPD with comorbid PTSD, and a control group of matched healthy individuals. Data collection encompasses clinical, cognitive, and neuroimaging domains commonly affected in both disorders, utilizing various imaging markers (including gray matter macrostructure, white matter microstructural integrity, and regional functional connectivity).

DISCUSSION

This study examines adolescent BPD with and without comorbid PTSD on clinical, neuroimaging, and cognitive levels. It is the first to use a comprehensive multi-modal approach within the same sample. Additionally, it uniquely explores hippocampal subfield volume differences in adolescents. Analysis of the relationship between the investigated domains and the effects of PTSD comorbidity will elucidate specific and shared alteration profiles in both disorders.

TRIAL REGISTRATION

IDRCB number 2019-A00366-51 / clinicaltrials.gov ID: NCT0485274. Registered on 21/04/2021.

Prefrontal cortex activation under stress as a function of borderline personality disorder in female adolescents engaging in non-suicidal self-injury

BACKGROUND

Neuroimaging studies suggest alterations in prefrontal cortex (PFC) activity in healthy adults under stress. Adolescents with non-suicidal self-injury (NSSI) report difficulties in stress and emotion regulation, which may be dependent on their level of borderline personality disorder (BPD).

AIMS

The aim was to examine alterations in the PFC in adolescents with NSSI during stress.

METHOD

Adolescents (13-17 years) engaging in non-suicidal self-injury (n = 30) and matched healthy controls (n = 29) performed a task with low cognitive demand and the Trier Social Stress Test (TSST). Mean PFC oxygenation across the PFC was measured with an eight-channel near-infrared spectroscopy system. Alongside self-reports on affect, dissociation and stress, BPD pathology was assessed via clinical interviews.

RESULTS

Mixed linear-effect models revealed a significant effect of time on PFC oxygenation and a significant time×group interaction, indicating increased PFC activity in patients engaging in NSSI at the beginning of the TSST compared with healthy controls. Greater BPD symptoms overall were associated with an increase in PFC oxygenation during stress. In exploratory analyses, mixed models addressing changes in PFC connectivity over time as a function of BPD symptoms were significant only for the left PFC.

CONCLUSIONS

Results indicate differences in the neural stress response in adolescents with NSSI in line with classic neuroimaging findings in adults with BPD. The link between PFC oxygenation and measures of BPD symptoms emphasises the need to further investigate adolescent risk-taking and self-harm across the spectrum of BPD, and maybe overall personality pathology, and could aid in the development of tailored therapeutic interventions.

Altered gray matter volume and functional connectivity in adolescent borderline personality disorder with non-suicidal self-injury behavior

BACKGROUND AND OBJECTIVES

Non-suicidal self-injury (NSSI) behavior is one of the characteristics of borderline personality disorder (BPD) in adolescents. Prior studies have shown that adolescents with BPD may have a unique pattern of brain alterations. The purpose of this study was to investigate the alterations in brain structure and function including gray matter volume and resting-state functional connectivity in adolescents with BPD, and to assess the association between NSSI behavior and brain changes on neuroimaging in adolescents with BPD.

METHODS

53 adolescents with BPD aged 12-17 years and 39 age-gender matched healthy controls (HCs) were enrolled into this study. Brain magnetic resonance imaging (MRI) was acquired with both 3D-T1 weighted structural imaging and resting-state functional imaging. Voxel-based morphometry (VBM) analysis for gray matter volume and seed-based functional connectivity (FC) analysis were performed for assessing gray matter volume and FC. Clinical assessment for NSSI, mood, and depression was also obtained. Correlative analysis of gray matter alterations with self-injury or mood scales were performed.

RESULTS

There were reductions of gray matter volume in the limbic-cortical circuit and default mode network in adolescents with BPD as compared to HCs (FWE P < 0.05, cluster size ≥ 1000). The diminished gray matter volumes in the left putamen and left middle occipital gyrus were negatively correlated with NSSI in adolescents with BPD (r = - 0.277 and P = 0.045, r = - 0.422 and P = 0.002, respectively). Furthermore, there were alterations of FC in these two regions with diminished gray matter volumes (voxel P < 0.001, cluster P < 0.05, FWE corrected).

CONCLUSIONS

Our results suggest that diminished gray matter volume of the limbic-cortical circuit and default mode network may be an important neural correlate in adolescent BPD. In addition, the reduced gray matter volume and the altered functional connectivity may be associated with NSSI behavior in adolescents with BPD.

Impaired decision-making in borderline personality disorder

Introduction

Borderline personality disorder (BPD) is a complex mental disorder with core symptoms like interpersonal instability, emotion dysregulation, self-harm, and impulsive decision-making. Previous neuropsychological studies have found impairment in the decision-making of patients with BPD related to impulsivity. In our study, we focus on a better, more nuanced understanding of impulsive decision-making in BPD with the help of Rogers' decision-making test that simulates a gambling situation.

Methods

A novelty of our study is that we excluded from further analysis non-compliant participants based on their performance. Outlier participants on the measures proportion of good choices and average of wager choice number were filtered out to represent the population that understood the basic premise of the task and showed minimal motivation to gain rewards. Thus participants often choosing the less likely color or frequently choosing the first bet amount available (to probably speed up the test) were omitted from further analysis. Another novelty is that we assessed and reported six variables that examine Deliberation Time, Quality of Decision, Risk-taking, Overall proportion bet, Delay aversion, and Risk adjustment. Forty-three women with BPD participated in the study, and 16 non-compliant were excluded. As for the healthy control group, 42 women participated in the study, and four non-compliant were excluded. Thus, we compared the data of 27 patients with BPD with 38 healthy controls.

Results

Our results show that there are significant differences amongst the groups regarding the Quality of Decision Making (F (1,63) = 5.801, p = 0.019) and Risk Adjustment (F (1,63) = 6.522, p = 0.013). We also found significant interactions between group and winning probability regarding Risk Taking (F (4,252) = 4.765 p = 0.001) and Overall proportion of bets, i.e., the average proportion of bets relative to the total score of the subject (F (4,252) = 4.505, p = 0.002).

Discussion

Our results show that the two groups use different decision-making strategies that can have various associations with everyday life situations.

Increased Right Dorsolateral Prefrontal Cortex Connectivity During Emotion Recognition Task in Adolescents With Self-Injurious Behavior: A Functional Near-Infrared Spectroscopy Study

OBJECTIVE

Research on neural correlates in the prefrontal cortex (PFC) associated with self-injurious behavior has mainly been performed in adults. However, studies on adolescents are scarce. We aimed to investigate the activation and connectivity of the PFC between adolescents with self-injurious behavior (ASI) and psychiatric controls (PC) using functional near-infrared spectroscopy (fNIRS).

METHODS

We used an emotion recognition task during fNIRS to assess 37 adolescents (23 with self-injurious behavior and 14 PC) between June 2020 and October 2021 and compared connectivity and activation between the two groups. We also measured adverse childhood events (ACE, Adverse Childhood Experiences) and performed a correlation analysis of channel activation according to ACE total scores.

RESULTS

The difference in activation between the groups was not statistically significant. The connectivity of channel 6 was statistically significant. The interaction between channel 6 and the ACE total score showed statistical significance between the two groups(t[33] -2.61; p=0.014). The ASI group showed a negative correlation with the total ACE score.

CONCLUSION

This is the first study to investigate PFC connectivity using fNIRS in ASI. It has the implication of a novel attempt with a practically useful tool to uncover neurobiological differences among Korean adolescents.

Childhood trauma is associated with reduced frontal gray matter volume: a large transdiagnostic structural MRI study

BACKGROUND

Childhood trauma increases risk for psychopathology and cognitive impairment. Prior research mainly focused on the hippocampus and amygdala in single diagnostic categories. However, other brain regions may be impacted by trauma as well, and effects may be independent of diagnosis. This cross-sectional study investigated cortical and subcortical gray matter volume in relation to childhood trauma severity.

METHODS

We included 554 participants: 250 bipolar-I patients, 84 schizophrenia-spectrum patients and 220 healthy individuals without a psychiatric history. Participants filled in the Childhood Trauma Questionnaire. Anatomical T1 MRI scans were acquired at 3T, regional brain morphology was assessed using Freesurfer.

RESULTS

In the total sample, trauma-related gray matter reductions were found in the frontal lobe (β = -0.049, p = 0.008; q = 0.048), this effect was driven by the right medial orbitofrontal, paracentral, superior frontal regions and the left precentral region. No trauma-related volume reductions were observed in any other (sub)cortical lobes nor the hippocampus or amygdala, trauma-by-group (i.e. both patient groups and healthy subjects) interaction effects were absent. A categorical approach confirmed a pattern of more pronounced frontal gray matter reductions in individuals reporting multiple forms of trauma and across quartiles of cumulative trauma scores. Similar dose-response patterns were revealed within the bipolar and healthy subgroups, but did not reach significance in schizophrenia-spectrum patients.

CONCLUSIONS

Findings show that childhood trauma is linked to frontal gray matter reductions, independent of psychiatric morbidity. Our results indicate that childhood trauma importantly contributes to the neurobiological changes commonly observed across psychiatric disorders. Frontal volume alterations may underpin affective and cognitive disturbances observed in trauma-exposed individuals.

Die Borderline-Persönlichkeitsstörung im Jugendalter

Zusammenfassung: Die Borderline-Persönlichkeitsstörung (BPS) ist eine schwere psychische Erkrankung, die durch hohe Morbidität und Mortalität gekennzeichnet ist sowie mit einem niedrigen psychosozialen Funktionsniveau einhergeht. Die BPS zeigt sich oft mit Beginn der frühen Adoleszenz (ab dem 12. Lebensjahr). Neben repetitiver Selbstverletzung und Suizidalität bestehen häufig sowohl Symptome internalisierender (Depression und Angst) als auch externalisierender Störungen (Hyperaktivität und Substanzkonsum). Daher kommt einer differentialdiagnostischen Abklärung und der Diagnosestellung mit dem Ziel der Frühintervention im klinischen Alltag eine besondere Rolle zu. Die Psychotherapie stellt bei der BPS eine äußerst wirksame Behandlungsmethode dar, Belege für die Wirksamkeit von pharmakologischen Intervention fehlen. Der Schlüssel zu einer Verbesserung der Versorgung für Jugendliche mit BPS liegt in einer Generierung von Wissen zu Vorläufersymptomen sowie einer evidenzbasierten, stadienspezifischen Behandlung (frühe Behandlung bereits subklinischer BPS mit Behandlungsintensität abgestuft nach dem Schweregrad). Dieser Übersichtsartikel beleuchtet den aktuellen Stand der Forschung und gibt Empfehlungen für die therapeutische Arbeit in der klinischen Praxis.

Common and distinct patterns of gray matter alterations in young adults with borderline personality disorder and major depressive disorder

Young adults with borderline personality disorder (BPD) and major depressive disorder (MDD) have a relatively high comorbidity rate; however, whether they share a neurobiological basis remains controversial. Although previous studies have reported respective brain alterations, the common and distinct gray matter changes between two disorders are still inconsistent. We conducted a meta-analysis using anisotropic effect size-based algorithms (ASE-SDM) to identify consistent findings from whole-brain voxel-based morphometry (VBM) studies of gray matter volume (GMV) in 274 young adults (< 45 years old) with BPD and 1576 with MDD. Compared with healthy controls, the young adults with BPD showed GMV reduction mainly in the prefrontal cortex including the inferior frontal gyrus and superior frontal gyrus, medial temporal network, and insula, whereas the MDD showed GMV alteration in the visual network (fusiform gyrus and inferior temporal gyrus), sensorimotor network (bilateral postcentral gyrus (PoCG) and right cerebellum) and left caudate nucleus. The GMV differences between these two disorders were concentrated in the left orbitofrontal cortex, cingulate cortex, right insula, and cerebellum. The meta-regression of the MDD group showed a negative association between disease duration and the right middle cingulate gyrus as well as negative associations between depressive symptoms and brain regions of the right cerebellum and the left PoCG. Our results identified common and distinct patterns of GMV alteration between BPD and MDD, which may provide neuroimage evidence for the disorder comorbidity mechanisms and partly indicate the similar and different biological features in emotion regulation of the two disorders. This study was registered with PROSPERO (CRD42020212758).

Early Intervention for Personality Disorder

Both the DSM-5 Section III Alternative Model for Personality Disorders and the ICD-11 have introduced a genuinely developmental approach to personality disorder. Among young people with personality disorder, compelling evidence demonstrates a high burden of disease, substantial morbidity, and premature mortality, as well as response to treatment. Yet, early diagnosis and treatment for the disorder have struggled to emerge from its identity as a controversial diagnosis to a mainstream focus for mental health services. Key reasons for this include stigma and discrimination, lack of knowledge about and failure to identify personality disorder among young people, along with the belief that personality disorder must always be addressed through lengthy and specialized individual psychotherapy programs. In fact, evidence suggests that early intervention for personality disorder should be a focus for all mental health clinicians who see young people and is feasible by using widely available clinical skills.

Efficacy and tolerability of Brain Stimulation interventions in Borderline Personality Disorder: state of the art and future perspectives - A systematic review

Treating Borderline Personality Disorder (BPD) is a major challenge for psychiatrists. As Brain Stimulation represents an alternative approach to treat psychiatric disorders, our systematic review is the first to focus on both invasive and Non-Invasive Brain Stimulation (NIBS) interventions in people living with BPD, examining clinical effects over core features and comorbid conditions. Following PRISMA guidelines, out of 422 original records, 24 papers were included regarding Deep Brain Stimulation (n = 1), Electroconvulsive therapy (n = 5), Transcranial Magnetic Stimulation (n = 13) and transcranial Direct Current Stimulation (n = 5). According to impulsivity and emotional dysregulated domain improvements, NIBS in BPD appears to restore frontolimbic network deficiencies. NIBS seems also to modulate depressive features. Safety and tolerability profiles for each technique are discussed. Despite encouraging results, definitive recommendations on Brain Stimulation in BPD are mitigated by protocols heterogeneity, lack of randomized controlled trials and poor quality of included studies, including high risk of methodological biases. To serve as guide for future systematic investigations, protocols optimization proposals are provided, focusing on alternative stimulation sites and suggesting a NIBS symptom-based approach.

Altered Resting-State Networks in Adolescent Non-Suicidal Self-Injury - A Graph Theory Analysis

Non-suicidal self-injury (NSSI) is a highly prevalent transdiagnostic symptom and risk marker for mental health problems among adolescents. Research on the neurobiological mechanisms underlying NSSI is needed to clarify the neural correlates associated with the behavior. We examined resting-state functional connectivity in n = 33 female adolescents aged 12–17 years engaging in NSSI, and in n = 29 age-matched healthy controls using graph theory. Mixed linear models were evaluated with the Bayes Factor to determine group differences on global and regional network measures and associations between network measures and clinical characteristics in patients. Adolescents engaging in NSSI demonstrated longer average characteristic path lengths and a smaller number of weighted hubs globally. Regional measures indicated lower efficiency and worse integration in (orbito)frontal regions and higher weighted coreness in the pericalcarine gyrus. In patients, higher orbitofrontal weighted local efficiency was associated with NSSI during the past month while lower pericalcarine nodal efficiency was associated with suicidal thoughts in the past year. Higher right but lower left pericalcarine weighted hubness was associated with more suicide attempts during the past year. Using a graph-based technique to identify functional connectivity networks, this study adds to the growing understanding of the neurobiology of NSSI.

Permutation Entropy as a Universal Disorder Criterion: How Disorders at Different Scale Levels Are Manifestations of the Same Underlying Principle

What do bacteria, cells, organs, people, and social communities have in common? At first sight, perhaps not much. They involve totally different agents and scale levels of observation. On second thought, however, perhaps they share everything. A growing body of literature suggests that living systems at different scale levels of observation follow the same architectural principles and process information in similar ways. Moreover, such systems appear to respond in similar ways to rising levels of stress, especially when stress levels approach near-lethal levels. To explain such communalities, we argue that all organisms (including humans) can be modeled as hierarchical Bayesian controls systems that are governed by the same biophysical principles. Such systems show generic changes when taxed beyond their ability to correct for environmental disturbances. Without exception, stressed organisms show rising levels of 'disorder' (randomness, unpredictability) in internal message passing and overt behavior. We argue that such changes can be explained by a collapse of allostatic (high-level integrative) control, which normally synchronizes activity of the various components of a living system to produce order. The selective overload and cascading failure of highly connected (hub) nodes flattens hierarchical control, producing maladaptive behavior. Thus, we present a theory according to which organic concepts such as stress, a loss of control, disorder, disease, and death can be operationalized in biophysical terms that apply to all scale levels of organization. Given the presumed universality of this mechanism, 'losing control' appears to involve the same process anywhere, whether involving bacteria succumbing to an antibiotic agent, people suffering from physical or mental disorders, or social systems slipping into warfare. On a practical note, measures of disorder may serve as early warning signs of system failure even when catastrophic failure is still some distance away.

Borderline Personality Disorder: Risk Factors and Early Detection

Personality disorders (PDs) exert a great toll on health resources, and this is especially true for borderline personality disorder (BPD). As all PDs, BPD arises during adolescence or young adulthood. It is therefore important to detect the presence of this PD in its earlier stages in order to initiate appropriate treatment, thus ameliorating the prognosis of this condition. This review aims to highlight the issues associated with BPD diagnosis in order to promote its early detection and treatment. To do so, we conducted a search on PubMed database of current evidence regarding BPD early diagnosis, focusing on risk factors, which represent important conditions to assess during young patient evaluation, and on diagnostic tools that can help the clinician in the assessment process. Our findings show how several risk factors, both environmental and genetic/neurobiological, can contribute to the onset of BPD and help identify at-risk patients who need careful monitoring. They also highlight the importance of a careful clinical evaluation aided by psychometric tests. Overall, the evidence gathered confirms the complexity of BDP early detection and its crucial importance for the outcome of this condition.

Mindfulness Effects on Mind Wandering and Autonomic Balance

The natural tendency of the mind to wander (i.e., mind wandering), is often connected to negative thoughts and emotional states. On the other hand, mindfulness (i.e., the ability to focus one's attention on the present moment in a non-judgmental way) has acquired a growing interest in recent years given its beneficial role in improving awareness and self-regulation. Starting from previous evidence, this study aims to clarify the psychological, physiological, and affective impact of a mindfulness exercise on mind wandering. Twenty-eight non-expert female meditators were recruited for this study. Heart rate variability (HRV), state mindfulness, mind wandering manifestations, and affective states, were recorded during a baseline condition, a mindfulness breathing observation exercise, and a final rest condition. Subjects reported significant decreases in mind wandering comparing baseline and mindfulness. Changes in mind wandering were mirrored by changes in HRV, with higher HRV during the breathing observation exercise. Significant associations were found between scores of mindfulness, mind wandering, and affective states measured during the task. Our findings confirmed the role of mindfulness in reducing mind wandering and increasing HRV. Results are discussed considering mindfulness associations with self-regulation and well-being.

Resting state prefrontal cortex oxygenation in adolescent non-suicidal self-injury - A near-infrared spectroscopy study

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Resting prefrontal cortex (PFC) oxygenation is decreased in adolescents with non-suicidal self-injury (NSSI) compared to healthy controls.

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Lower PFC oxygenation (full sample) is associated with greater adverse childhood experiences and less health-related quality of life (HRQoL).

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On the group-level, patients show no alterations of resting state functional connectivity within the PFC.

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Among other clinical variables, increased PFC connectivity (full sample) is associated with greater borderline personality pathology.

Introduction

Neural alterations in limbic and prefrontal circuits in association with self-injurious behavior have been studied primarily in adult borderline personality disorder (BPD). In adolescent patients, research is still sparse. Here, we used resting functional near-infrared spectroscopy (NIRS) to examine oxygenation of the prefrontal cortex (PFC) and its association with symptom severity in adolescents engaging in non-suicidal self-injury (NSSI) and matched healthy controls (HC).

Methods

Adolescents (12–17 years) with recurrent episodes of NSSI (n = 170) and healthy controls (n = 43) performed a low-demanding resting-state vanilla baseline task. Mean oxygenation of the PFC and functional connectivity within the PFC, were measured using an 8-channel functional NIRS system (Octamon, Artinis, The Netherlands). Various clinical variables derived from diagnostic interviews and self-reports were included in statistical analyses to explore potential associations with PFC oxygenation and connectivity.

Results

Adolescents with NSSI showed significantly decreased PFC oxygenation compared to HC, as indexed by oxygenated hemoglobin. Lower PFC oxygenation was associated with greater adverse childhood experiences and less health-related quality of life (HRQoL). While there was no evidence for alterations in PFC connectivity in adolescents engaging in NSSI compared to HC, increased PFC connectivity in the full sample was associated with greater adverse childhood experience, greater BPD pathology, greater depression severity and psychological burden in general, as well as lower HRQoL.

Conclusion

This study is the first to examine PFC oxygenation using NIRS technology in adolescents engaging in NSSI. Overall, results indicate small effects not specific to NSSI. Clinical implications of these findings and recommendations for further research are discussed.

Structural brain abnormalities in borderline personality disorder correlate with clinical severity and predict psychotherapy response

Although previous imaging studies in borderline personality disorder (BPD) have found brain abnormalities, the results have been inconsistent. This study aimed to investigate structural brain abnormalities using voxel-based morphometry (VBM) and cortical thickness (Cth) analyses in a large sample of patients with BPD. Additionally, we aimed to determine the correlation between structural abnormalities and clinical severity and to assess its potential value at predicting psychotherapeutic response. Sixty-one individuals with BPD and 19 healthy controls underwent magnetic resonance imaging. Participants with BPD completed several self-report clinical scales, received dialectical-behavioral therapy skills training and post-therapy changes in clinical scores were also recorded. Gray matter volume (GMV) and Cth differences between groups were compared. Within the BPD group, we further characterized the structural brain correlates of clinical severity and investigated the relationship between pre-therapy structural abnormalities and therapeutic response. As potential confounders we included age, sex, educational level, and total intracranial volume (the latter only in VBM analyses). Compared to controls, the BPD group showed a reduced GMV/Cth in prefrontal areas but increased GMV in the limbic structures (amygdala and parahippocampal regions). Prefrontal abnormalities correlated with higher baseline scores on impulsivity and general BPD severity. Increased GMV in the parahippocampal area correlated with a greater emotion dysregulation. Importantly, several baseline structural abnormalities correlated with worse response to psychotherapy. Patients with BPD showed a reduced GMV in the prefrontal areas but a greater GMV in the limbic structures. Several structural abnormalities (i.e. middle and inferior prefrontal areas, anterior insula, or parahippocampal area) correlated with clinical severity and could potentially be used as imaging biological correlates biomarkers to predict psychotherapy response.

How higher goals are constructed and collapse under stress: A hierarchical Bayesian control systems perspective

In this paper, we show that organisms can be modeled as hierarchical Bayesian control systems with small world and information bottleneck (bow-tie) network structure. Such systems combine hierarchical perception with hierarchical goal setting and hierarchical action control. We argue that hierarchical Bayesian control systems produce deep hierarchies of goal states, from which it follows that organisms must have some form of 'highest goals'. For all organisms, these involve internal (self) models, external (social) models and overarching (normative) models. We show that goal hierarchies tend to decompose in a top-down manner under severe and prolonged levels of stress. This produces behavior that favors short-term and self-referential goals over long term, social and/or normative goals. The collapse of goal hierarchies is universally accompanied by an increase in entropy (disorder) in control systems that can serve as an early warning sign for tipping points (disease or death of the organism). In humans, learning goal hierarchies corresponds to personality development (maturation). The failure of goal hierarchies to mature properly corresponds to personality deficits. A top-down collapse of such hierarchies under stress is identified as a common factor in all forms of episodic mental disorders (psychopathology). The paper concludes by discussing ways of testing these hypotheses empirically.

Brain Connectivity and Symptom Changes After Transcranial Magnetic Stimulation in Patients With Borderline Personality Disorder

OBJECTIVES

Repetitive transcranial magnetic stimulation (rTMS) is an innovative method in the treatment of borderline personality disorder (BPD). We hypothesized that prefrontal rTMS in patients with BPD leads to improved BPD symptoms and that these effects are associated with brain connectivity changes.

METHODS

Fourteen patients with BPD received 15 sessions of individually navigated prefrontal rTMS over the right dorsolateral prefrontal cortex. Clinical effects were measured by the Borderline Symptom List 23, UPPS-P, the Difficulties in Emotion Regulation Scale (DERS), the Zung Self-Rating Anxiety Scale (SAS), and the Montgomery and Åsberg Depression Rating Scale (MADRS). Effects of rTMS on brain connectivity were observed with a seed correlation analysis on resting-state fMRI and with a beta series correlation analysis on Go/No Go tasks during fMRI. Assessments were made before and immediately after the treatment.

RESULTS

The assessments after rTMS showed significant reductions in two subscales of UPPS-P, and in DERS, SAS, and MADRS. The brain connectivity analysis revealed significant decreases in amygdala and insula connectivity with nodes of the posterior default mode network (pDMN; precuneus, posterior cingulate cortex, parietal lobules). Connectivity changes were observed both in the resting state and during inhibition. The decrease of amygdala-pDMN connectivity was positively correlated with reduced depression and lack of premeditation after rTMS.

CONCLUSIONS

Despite the study limitations (open single-arm study in a small sample), our findings suggest a possible neural mechanism of rTMS effect in BPD, reduced amygdala connectivity with the pDMN network, which was positively associated with symptom reduction.

Common and distinct patterns of gray matter alterations in borderline personality disorder and posttraumatic stress disorder: A dual meta-analysis

BACKGROUND

Borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) are severe psychiatric disorders and often co-occur, either of the two will seriously threaten to public health. However, we lack ample evidences to understand the potential pathophysiologic mechanisms of gray matter (GM) alterations in the two disorders.

METHODS

We performed a meta-analysis in both BPD (15 datasets including 442 BPD subjects versus 441 healthy controls) and PTSD (11 datasets including 214 PTSD subjects versus 258 healthy controls) applying anisotropic effect-size-based algorithms (AES-SDM) method.

RESULTS

Conjunction analysis found relative GM volume reductions in both disorders in the orbitofrontal gyrus and anterior cingulate cortex, contrarily, differences were predominantly observed that GM volume increased in the posterior cingulate gyrus and precuneus in BPD subjects, and GM volume decreased in the amygdala-hippocampal fear circuit, fusiform gyrus in PTSD subjects.

CONCLUSIONS

Group comparisons and conjunction analyses in BPD and PTSD identified same regions of GM volume reductions in the orbitofrontal gyrus and anterior cingulate cortex, which may provide clues for the neurobiological mechanisms and clinical diagnosis underpinning two disorders.

Brain structure and symptom dimensions in borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) presents with symptoms across different domains, whose neurobiology is poorly understood.

METHODS

We applied voxel-based morphometry on high-resolution magnetic resonance imaging scans of 19 female BPD patients and 50 matched female controls.

RESULTS

Group comparison showed bilateral orbitofrontal gray matter loss in patients, but no significant changes in the hippocampus. Voxel-wise correlation of gray matter with symptom severity scores from the Borderline Symptom List (BSL-95) showed overall negative correlation in bilateral prefrontal, right inferior temporal/fusiform and occipital cortices, and left thalamus. Significant (negative) correlations with BSL-95 subscores within the patient cohort linked autoaggression to left lateral prefrontal and insular cortices, right inferior temporal/temporal pole, and right orbital cortex; dysthymia/dysphoria to right orbitofrontal cortex; self-perception to left postcentral, bilateral inferior/middle temporal, right orbitofrontal, and occipital cortices. Schema therapy-based Young Schema Questionnaire (YSQ-S2) scores of early maladaptive schemas on emotional deprivation were linked to left medial temporal lobe gray matter reductions.

CONCLUSIONS

Our results confirm orbitofrontal structural deficits in BPD, while providing a framework and preliminary findings on identifying structural correlates of symptom dimensions in BPD, especially with dorsolateral and orbitofrontal cortices.

Effects of hydrocortisone on autobiographical memory retrieval in patients with posttraumatic stress disorder and borderline personality disorder: the role of childhood trauma

In a previous study, we found that patients with posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) showed better autobiographical memory (AM) retrieval after hydrocortisone administration than after placebo administration. Here we investigate the neural correlates of AM retrieval after hydrocortisone administration in patients with PTSD or BPD. We recruited 78 female participants for this placebo-controlled crossover study: 40 healthy controls, 20 patients with PTSD, and 18 patients with BPD (all without medication). All participants received an oral placebo or 10 mg hydrocortisone in a randomized order before performing an AM task. Neural activity was monitored during the task by functional magnetic resonance imaging. Neural activation did not differ between the three groups during AM retrieval, neither in the placebo condition nor after hydrocortisone intake. Multiple regression analysis revealed that Childhood Trauma Questionnaire scores correlated positively with hydrocortisone effects on activation in the anterior medial prefrontal cortex (amPFC), ventrolateral prefrontal cortex (vlPFC), posterior cingulate cortex (PCC), angular gyrus, and cerebellum. These results suggest that hydrocortisone-induced neural activation pattern during AM retrieval is related to childhood trauma. Previously described effects in the hippocampus, which were absent in the current study, might be related to PTSD caused by trauma in adulthood. The effects of hydrocortisone on brain activation and how these effects are influenced by childhood trauma, trauma in adulthood, and PTSD symptoms should be determined in future studies.

Self-injuring adolescent girls exhibit insular cortex volumetric abnormalities that are similar to those seen in adults with borderline personality disorder

Self-inflicted injury (SII) in adolescence is a serious public health concern that portends prospective vulnerability to internalizing and externalizing psychopathology, borderline personality development, suicide attempts, and suicide. To date, however, our understanding of neurobiological vulnerabilities to SII is limited. Behaviorally, affect dysregulation is common among those who self-injure. This suggests ineffective cortical modulation of emotion, as observed among adults with borderline personality disorder. In borderline samples, structural and functional abnormalities are observed in several frontal regions that subserve emotion regulation (e.g., anterior cingulate, insula, dorsolateral prefrontal cortex). However, no volumetric analyses of cortical brain regions have been conducted among self-injuring adolescents. We used voxel-based morphometry to compare cortical gray matter volumes between self-injuring adolescent girls, ages 13-19 years (n = 20), and controls (n = 20). Whole-brain analyses revealed reduced gray matter volumes among self-injurers in the insular cortex bilaterally, and in the right inferior frontal gyrus, an adjacent neural structure also implicated in emotion and self-regulation. Insular and inferior frontal gyrus gray matter volumes correlated inversely with self-reported emotion dysregulation, over-and-above effects of psychopathology. Findings are consistent with an emotion dysregulation construal of SII, and indicate structural abnormalities in some but not all cortical brain regions implicated in borderline personality disorder among adults.

Common and distinct patterns of grey matter alterations in borderline personality disorder and bipolar disorder: voxel-based meta-analysis

BACKGROUND

Whether borderline personality disorder (BPD) and bipolar disorder are the same or different disorders lacks consistency.AimsTo detect whether grey matter volume (GMV) and grey matter density (GMD) alterations show any similarities or differences between BPD and bipolar disorder.

METHOD

Web-based publication databases were searched to conduct a meta-analysis of all voxel-based studies that compared BPD or bipolar disorder with healthy controls. We included 13 BPD studies (395 patients with BPD and 415 healthy controls) and 47 bipolar disorder studies (2111 patients with bipolar disorder and 3261 healthy controls). Peak coordinates from clusters with significant group differences were extracted. Effect-size signed differential mapping meta-analysis was performed to analyse peak coordinates of clusters and thresholds (P &lt; 0.005, uncorrected). Conjunction analyses identified regions in which disorders showed common patterns of volumetric alteration. Correlation analyses were also performed.

RESULTS

Patients with BPD showed decreased GMV and GMD in the bilateral medial prefrontal cortex network (mPFC), bilateral amygdala and right parahippocampal gyrus; patients with bipolar disorder showed decreased GMV and GMD in the bilateral medial orbital frontal cortex (mOFC), right insula and right thalamus, and increased GMV and GMD in the right putamen. Multi-modal analysis indicated smaller volumes in both disorders in clusters in the right medial orbital frontal cortex. Decreased bilateral mPFC in BPD was partly mediated by patient age. Increased GMV and GMD of the right putamen was positively correlated with Young Mania Rating Scale scores in bipolar disorder.

CONCLUSIONS

Our results show different patterns of GMV and GMD alteration and do not support the hypothesis that bipolar disorder and BPD are on the same affective spectrum.Declaration of interestNone.

Borderline personality disorder and emotion dysregulation

Borderline personality disorder (BPD) is a severe and complex disorder characterized by instability across many life domains, including interpersonal relations, behavior, and emotions. A core feature and contributor to BPD, emotion dysegulation (ED), consists of deficits in the ability to regulate emotions in a manner that allows the individual to pursue important goals or behave effectively in various contexts. Biosocial developmental models of BPD have emphasized a transaction of environmental conditions (e.g., invalidating environments and adverse childhood experiences) with key genetically linked vulnerabilities (e.g., impulsivity and emotional vulnerability) in the development of ED and BPD. Emerging evidence has begun to highlight the complex, heterotypic pathways to the development of BPD, with key heritable vulnerability factors possibly interacting with aspects of the rearing environment to produce worsening ED and an adolescent trajectory consisting of self-damaging behaviors and eventual BPD. Adults with BPD have shown evidence of a variety of cognitive, physiological, and behavioral characteristics of ED. As the precursors to the development of ED and BPD have become clearer, prevention and treatment efforts hold great promise for reducing the long-term suffering, functional impairment, and considerable societal costs associated with BPD.

Early Detection and Outcome in Borderline Personality Disorder

Borderline personality disorder (BPD) is a severe and heterogeneous mental disorder that is known to have the onset in young age, often in adolescence. For this reason, it is of fundamental importance to identify clinical conditions of childhood and adolescence that present a high risk to evolve in BPD. Investigations indicate that early borderline pathology (before 19 years) predict long-term deficits in functioning, and a higher percentage of these patients continue to present some BPD symptoms up to 20 years. There is a general accordance among investigators that good competence in both childhood and early adulthood is the main predictive factor of excellent recovery in BPD patients. Some authors suggest that specific childhood personality traits can to be considered precursors of adult BPD, as well as some clinical conditions: disruptive behaviours, disturbance in attention and emotional regulation, conduct disorders, substance use disorders, and attention-deficit-hyperactivity disorder. Unfortunately, diagnosis and treatment of BPD is usually delayed, also because some clinicians are reluctant to diagnose BPD in younger individuals. Instead, the early identification of BPD symptoms have important clinical implications in terms of precocious intervention programs, and guarantees that young people with personality disorders obtain appropriate treatments. This review is aimed to collect the current evidences on early risk and protective factors in young people that may predict BPD onset, course, and outcome.

Regional grey matter volume reduction in adolescents engaging in non-suicidal self-injury

There is a high prevalence of non-suicidal self-injury (NSSI) amongst adolescents worldwide and therefore an urgency to investigate the underlying mechanisms that may facilitate such behaviours. This study aimed to investigate neurobiological alterations, specifically in regional brain volumes of the frontolimbic system, in adolescents engaging in NSSI in comparison to healthy controls. Regional grey matter volumes were compared between 29 adolescent female patients who presented with incidents of NSSI on ≥5 days within the last 12 months (DSM-5 criteria for NSSI) and 21 healthy age, gender and education matched controls who had never received any psychiatric diagnosis/treatment, or engaged in NSSI. Significant group effects in regional brain volumes were observed in insula, and a suggested change in the anterior cingulate cortex (ACC), while controlling for total segmented volume. Additionally, ACC volume showed a significant association with past suicide attempts, where estimated marginal means showed even smaller ACC volume in adolescents engaging in NSSI with a history of suicide attempt in comparison to those with no history of suicide attempt, including healthy controls. This study provides the first evidence of volumetric changes in adolescents engaging in NSSI and a potential neurobiological link between NSSI and suicide attempt.

Heightened Salience of Anger and Aggression in Female Adolescents With Borderline Personality Disorder-A Script-Based fMRI Study

Background: Anger and aggression belong to the core symptoms of borderline personality disorder. Although an early and specific treatment of BPD is highly relevant to prevent chronification, still little is known about anger and aggression and their neural underpinnings in adolescents with BPD.

Method: Twenty female adolescents with BPD (age 15–17 years) and 20 female healthy adolescents (age 15–17 years) took part in this functional magnetic resonance imaging (fMRI) study. A script-driven imagery paradigm was used to induce rejection-based feelings of anger, which was followed by descriptions of self-directed and other-directed aggressive reactions. To investigate the specificity of the neural activation patterns for adolescent patients, results were compared with data from 34 female adults with BPD (age 18–50 years) and 32 female healthy adults (age 18–50 years).

Results: Adolescents with BPD showed increased activations in the left posterior insula and left dorsal striatum as well as in the left inferior frontal cortex and parts of the mentalizing network during the rejection-based anger induction and the imagination of aggressive reactions compared to healthy adolescents. For the other-directed aggression phase, a significant diagnosis by age interaction confirmed that these results were specific for adolescents.

Discussion: The results of this very first fMRI study on anger and aggression in adolescents with BPD suggest an enhanced emotional reactivity to and higher effort in controlling anger and aggression evoked by social rejection at an early developmental stage of the disorder. Since emotion dysregulation is a known mediator for aggression in BPD, the results point to the need of appropriate early interventions for adolescents with BPD.

Reduced white matter integrity in borderline personality disorder: A diffusion tensor imaging study

BACKGROUND

Borderline personality disorder (BPD) has a pervasive pattern of instability in interpersonal relationships, self-image, and emotions. BPD may be linked to an abnormal brain anatomy, but little is known about possible impairments of the white matter microstructure in BPD or their relationship with impulsivity or risky behaviors. The aims of the present study were to explore the relationship between BPD and diffusion tensor imaging (DTI) parameters and psychological tests.

METHODS

We evaluated 35 un-medicated BPD patients in a medication-free state and 50 healthy controls (HCs). We performed DTI tractography in BPD patients and HCs. The Childhood Trauma Questionnaire (CTQ), Profile of Mood State (POMS), State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI), Social Adaptation Self-Evaluation Scale (SASS), and Depression and Anxiety Cognition Scale (DACS) were administered to BPD patients and HCs.

RESULTS

A tract-based spatial statistics (TBSS) revealed that the BPD group had three clusters with a significantly lower axial diffusivity (AD) than the HC group: one located mainly in the cingulum and the other mainly in the inferior front-occipital fasciculus and inferior longitudinal fasciculus. Regarding the AD values, one cluster correlated negatively and significantly with POMS (Depression) and it was located in the cingulum, while another cluster correlated positively and significantly with DACS (Future Denial) and it was located in the inferior front-occipital fasciculus (IFOF).

LIMITATIONS

The small sample size of this study prevents us from forming any definitive conclusions, meaning that more studies are needed to confirm our findings. We are unable to generalize our findings to include other ethnic groups.

CONCLUSIONS

Our results suggested that hypo-metabolism in a front-limbic network dysfunction is characterized by the cingulum and a front-occipital network dysfunction characterized by the occipital lobe, while an occipital-temporal network dysfunction characterized by the inferior longitudinal fasciculus.

Assessing the marks of change: how psychotherapy alters the brain structure in women with borderline personality disorder

BACKGROUND

There is increasing evidence that psychotherapy can alter the function of the brain of patients with borderline personality disorder (BPD). However, it is not known whether psychotherapy can also modify the brain structure of patients with BPD.

METHODS

We used structural MRI data of female patients with BPD before and after participation in 12 weeks of residential dialectical behavioural therapy (DBT) and compared them to data from female patients with BPD who received treatment as usual (TAU). We applied voxel-based morphometry to study voxel-wise changes in grey matter volume over time.

RESULTS

We included 31 patients in the DBT group and 17 in the TAU group. Patients receiving DBT showed an increase of grey matter volume in the anterior cingulate cortex, inferior frontal gyrus and superior temporal gyrus together with an alteration of grey matter volume in the angular gyrus and supramarginal gyrus compared with patients receiving TAU. Furthermore, therapy response correlated with increase of grey matter volume in the angular gyrus.

LIMITATIONS

Only women were investigated, and groups differed in size, medication (controlled for) and intensity of the treatment condition.

CONCLUSION

We found that DBT increased grey matter volume of brain regions that are critically implicated in emotion regulation and higher-order functions, such as mentalizing. The role of the angular gyrus for treatment response may reside in its cross-modal integrative function. These findings enhance our understanding of psychotherapy mechanisms of change and may foster the development of neurobiologically informed therapeutic interventions.

Amygdala and dlPFC abnormalities, with aberrant connectivity and habituation in response to emotional stimuli in females with BPD

BACKGROUND

Little is known about the frontolimbic abnormalities thought to underlie borderline personality disorder (BPD). We endeavoured to study regional responses, as well as their connectivity and habituation during emotion processing.

METHODS

14 BPD patients and 14 normal female controls (NC) controlled for menstrual phase underwent emotion-induction during an fMRI task using standardised images in a block design. We then performed psychophysiological interaction (PPI) analysis to investigate functional connectivity.

RESULTS

BPD patients reported more disgust in questionnaires compared to controls. Relative to NC, they showed reduced left amygdala and increased dorsolateral prefrontal cortex (dlPFC) activation to all emotions collapsed versus neutral. Habituation of ventral striatal activity to repeated emotional stimuli was observed in controls but not in BPD. Finally, in the context of disgust (but not other emotions) versus neutral, BPD patients displayed enhanced left amygdala coupling with the dlPFC and ventral striatum.

LIMITATIONS

Strict inclusion criteria reduced the sample size.

CONCLUSIONS

In summary, BPD showed abnormal patterns of activation, habituation and connectivity in regions linked to emotion regulation. Amygdala deactivation may be mediated by abnormal top-down regulatory control from the dorsolateral prefrontal cortex. Aberrant emotion processing may play a unique role in the pathophysiology of BPD.

Repetitive TMS on Left Cerebellum Affects Impulsivity in Borderline Personality Disorder: A Pilot Study

The borderline personality disorder (BPD) is characterized by a severe pattern of instability in emotional regulation, interpersonal relationships, identity and impulse control. These functions are related to the prefrontal cortex (PFC), and since PFC shows a rich anatomical connectivity with the cerebellum, the functionality of the cerebellar-PFC axis may impact on BPD. In this study, we investigated the potential involvement of cerebello-thalamo-cortical connections in impulsive reactions through a pre/post stimulation design. BPD patients (n = 8) and healthy controls (HC; n = 9) performed an Affective Go/No-Go task (AGN) assessing information processing biases for positive and negative stimuli before and after repetitive transcranial magnetic stimulation (rTMS; 1 Hz/10 min, 80% resting motor threshold (RMT) over the left lateral cerebellum. The AGN task consisted of four blocks requiring associative capacities of increasing complexity. BPD patients performed significantly worse than the HC, especially when cognitive demands were high (third and fourth block), but their performance approached that of HC after rTMS (rTMS was almost ineffective in HC). The more evident effect of rTMS in complex associative tasks might have occurred since the cerebellum is deeply involved in integration and coordination of different stimuli. We hypothesize that in BPD patients, cerebello-thalamo-cortical communication is altered, resulting in emotional dysregulation and disturbed impulse control. The rTMS over the left cerebellum might have interfered with existing functional connections exerting a facilitating effect on PFC control.

Abnormal white matter structural connectivity in treatment-naïve young adults with borderline personality disorder

OBJECTIVE

The pathogenesis of borderline personality disorder (BPD) is not well understood. We examined the microstructure of white matter in patients with BPD.

METHOD

Treatment-naïve young adult with BPD (N = 30) and young-adult healthy controls (HCs; N = 31) were subjected diffusion tensor imaging (DTI). Microstructural parameters were analyzed via tract-based spatial statistics (TBSS) and post hoc tractography.

RESULTS

TBSS analysis revealed that, relative to the HC group, the BPD group had significantly lower fractional anisotropy (FA) values in the genu and body of the corpus callosum (CC), right superior corona radiate, right anterior corona radiate, as well as higher radial diffusivity (RD) in the left anterior thalamic radiation. Tractography showed that FA values of fiber bundles passing through the fornix were significantly reduced in BPD group relative to HCs. No significant correlations were observed between clinical symptom and DTI indices in BPD group (FDR corrected).

CONCLUSION

Focal microstructural alterations were found in BPD group, mainly in the limbic system and CC. The present findings support the fronto-limbic disconnectivity hypothesis and suggest that abnormal maturation of white matter structures may play an important role in mechanism of BPD.

A systematic review of the neurobiological underpinnings of borderline personality disorder (BPD) in childhood and adolescence

Contemporary theories for the aetiology of borderline personality disorder (BPD) take a lifespan approach asserting that inborn biological predisposition is potentiated across development by environmental risk factors. In this review, we present and critically evaluate evidence on the neurobiology of BPD in childhood and adolescence, compare this evidence to the adult literature, and contextualise within a neurodevelopmental framework. A systematic review was conducted to identify studies examining the neurobiological (i.e. genetic, structural neuroimaging, neurophysiological, and neuropsychological) correlates of BPD symptoms in children and adolescents aged 19 years or under. We identified, quality assessed, and narratively summarised 34 studies published between 1980 and June 2016. Similar to findings in adult populations, twin studies indicated moderate to high levels of heritability of BPD, and there was some evidence for gene-environment interactions. Also consistent with adult reports is that some adolescents with BPD demonstrated structural (grey and white matter) alterations in frontolimbic regions and neuropsychological abnormalities (i.e. reduced executive function and disturbances in social cognition). These findings suggest that neurobiological abnormalities observed in adult BPD may not solely be the consequence of chronic morbidity or prolonged medication use. They also provide tentative support for neurodevelopmental theories of BPD by demonstrating that neurobiological markers may be observed from childhood onwards and interact with environmental factors to increase risk of BPD in young populations. Prospective studies with a range of repeated measures are now required to elucidate the temporal unfurling of neurobiological features and further delineate the complex pathways to BPD.

Disadvantageous decision-making in borderline personality disorder: Partial support from a meta-analytic review

To achieve long-term goals, organisms evaluate outcomes and expected consequences of their behaviors. Unfavorable decisions maintain many symptoms of borderline personality disorder (BPD); therefore, a better understanding of the mechanisms underlying decision-making in BPD is needed. In this review, the current literature comparing decision-making in patients with BPD versus healthy controls is analyzed. Twenty-eight empirical studies were identified through a structured literature search. The effect sizes from studies applying comparable experimental tasks were analyzed. It was found that (1) BPD patients discounted delayed rewards more strongly; (2) reversal learning was not significantly altered in BPD; and (3) BPD patients achieved lower net gains in the Iowa Gambling Task (IGT). Current psychotropic medication, sex and differences in age between the patient and control group moderated the IGT outcome. Altered decision-making in a variety of other tasks was supported by a qualitative review. In summary, current evidence supports the altered valuation of outcomes in BPD. A multifaceted influence on decision-making and adaptive learning is reflected in this literature.

Default mode network and frontolimbic gray matter abnormalities in patients with borderline personality disorder: A voxel-based meta-analysis

Specific frontolimbic abnormalities are hypothesized to underlie the etiology of borderline personality disorder (BPD). However, findings from neuroimaging studies were inconsistent. In the current study, we aimed to provide a complete overview of cerebral microstructural alterations in gray matter (GM) of BPD patients. A total of 11 studies were enrolled, comprising 275 BPD patients and 290 healthy controls (HCs). A meta-analysis was conduct to quantitatively estimate regional GM abnormalities in BPD patients using the seed-based d mapping (SDM). Meta-regression was also conducted. Compared with HCs, the BPD patients exhibited increased GM mainly in bilateral supplementary motor area extending to right posterior cingulated cortex (PCC) and bilateral primary motor cortex, right middle frontal gyrus (MFG), and the bilateral precuneus extending to bilateral PCC. Decreased GM was identified in bilateral middle temporal gyri, right inferior frontal gyrus extending to right insular, left hippocampus and left superior frontal gyrus extending to left medial orbitofrontal cortex. The mean age of BPD patients were found nagativly associated with GM alterations in right MFG. Our findings suggested that BPD patients have significantly GM abnormalities in the default mode network and frontolimbic circuit. Our results provided further evidences in elucidating the underline neural mechanisms of BPD.

Dual-task performance under acute stress in female adolescents with borderline personality disorder

Research to elucidate early alterations of higher cognitive processes in adolescents with BPD is rare. This study investigated differences in dual-task performance in adolescents with BPD during stress and non-stress conditions. The study sample comprised 30 female adolescents with BPD and 34 healthy controls. The impact of stress on dual-task performance was measured using a standardized stressor. Self-reports of distress and measures of heart rate (HR) were obtained to measure stress reactivity. There were no group differences in task performance. Under stress conditions, the performance on the auditory task decreased in both groups but without significant group differences. Healthy controls showed an increase of mean HR after stress induction compared to no change in the BPD group. The finding of attenuated HR response to acute stress in adolescent patients with BPD may contradict current theories that the affective hyperresponsivity in BPD is based on a biologically determined mechanism.

Neuroimagerie fonctionnelle chez l’adolescent avec un trouble de personnalité limite

De nombreuses études en neuroimagerie fonctionnelle (IRMf) menées chez les adultes présentant un trouble de personnalité limite (TPL) convergent pour identifier un patron d’activation neuronale, notamment fronto-limbique, différent de celui activé chez les adultes sans TPL lors des tâches de visualisation d’images émotionnelles. À ce jour, aucune étude en IRMf n’a été réalisée chez les adolescents avec TPL. Ce projet pilote vise à évaluer la faisabilité d’un protocole d’IRMf chez des adolescentes avec TPL et à identifier les régions neuronales d’intérêt pour les études de neuroimagerie chez cette population. Le projet porte sur six adolescentes euthymiques présentant un diagnostic de TPL (âge moyen : 15,8 ± 0,9 ans) et six adolescentes témoins sans diagnostic psychiatrique (âge moyen : 15,5 ± 1,2 ans). Après l’évaluation diagnostique incluant le Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime et le Diagnostic Interview for Borderline – Revised version, les participantes ont complété une tâche d’IRMf au cours de laquelle elles devaient regarder 20 images à valence affective positive, 20 images à valence affective négative et 20 images neutres. L’étude de faisabilité montre que les participantes ont été recrutées en 22 mois et que le protocole était bien toléré par celles-ci. Les résultats montrent que le visionnement des scènes positives et négatives a entraîné une plus grande activation de plusieurs aires limbiques ainsi que frontales, temporales et du cervelet chez le groupe TPL. Les aires limbiques et préfrontales semblent être des régions d’intérêt dans l’étude du fonctionnement neuronal chez les adolescentes avec TPL.

Age-related parieto-occipital and other gray matter changes in borderline personality disorder: A meta-analysis of cortical and subcortical structures

Previous research suggests that core borderline personality disorder (BPD) symptoms vary in severity with advancing age. While structural neuroimaging studies show smaller limbic and prefrontal gray matter volumes (GMV) in primarily adult and adolescent BPD patients, respectively, findings are inconsistent. Using the effect-size signed differential mapping (ES-SDM) meta-analytic method, we investigated the relationship between advancing age and GMV abnormalities in BPD patients. A total of nine voxel-based morphometry (VBM) studies comparing regional GMV of 256 BPD patients and 272 healthy control subjects were included. Meta-analysis identified lower GMV in the right superior/middle temporal gyri and higher GMV in the right supplementary motor area of BPD patients. Meta-regression showed that increasing age was significantly associated with increased GMV in the left superior parieto-occipital gyri, with younger-aged patients starting at lower GMV compared to controls. In contrast, increasing age was associated with decreased GMV in the right amygdala. These findings suggest that while GMV deficits in limbic structures may become pronounced with advancing age in the course of BPD, parieto-occipital rather than frontal GMV deficits could be especially prominent in younger-aged BPD patients.

A Voxel-Based Morphometric MRI Study in Young Adults with Borderline Personality Disorder

BACKGROUND

Increasing evidence has documented subtle changes in brain morphology and function in patients with borderline personality disorder (BPD). However, results of magnetic resonance imaging volumetry in patients with BPD are inconsistent. In addition, few researchers using voxel-based morphometry (VBM) have focused on attachment and childhood trauma in BPD. This preliminary study was performed to investigate structural brain changes and their relationships to attachment and childhood trauma in a homogenous sample of young adults with BPD.

METHOD

We examined 34 young adults with BPD and 34 healthy controls (HCs) to assess regionally specific differences in gray matter volume (GMV) and gray matter concentration (GMC). Multiple regressions between brain volumes measured by VBM and attachment style questionnaire (ASQ) and childhood trauma questionnaire (CTQ) scores were performed.

RESULTS

Compared with HCs, subjects with BPD showed significant bilateral increases in GMV in the middle cingulate cortex (MCC)/posterior cingulate cortex (PCC)/precuneus. GMC did not differ significantly between groups. In multiple regression models, ASQ insecure attachment scores were correlated negatively with GMV in the precuneus/MCC and middle occipital gyrus in HCs, HCs with more severe insecure attachment showed smaller volumes in precuneus/MCC and middle occipital gyrus, whereas no negative correlations between insecure attachment and GMV in any region were found in BPD group. In addition, CTQ total scores were not correlated with GMV in any region in the two groups respectively.

CONCLUSIONS

Our findings fit with those of previous reports of larger precuneus GMV in patients with BPD, and suggest that GMV in the precuneus/MCC and middle occipital gyrus is associated inversely with insecure attachment style in HCs. Our finding of increased GMV in the MCC and PCC in patients with BPD compared with HCs has not been reported in previous VBM studies.

Neural Correlates of Disturbed Emotion Processing in Borderline Personality Disorder: A Multimodal Meta-Analysis

BACKGROUND

Disturbances in the processing and regulation of emotions are core symptoms of borderline personality disorder (BPD). To further elucidate neural underpinnings of BPD, the present meta-analysis summarizes functional neuroimaging findings of emotion processing tasks, as well as structural neuroimaging findings, and investigates multimodally affected brain regions.

METHODS

Combined coordinate- and image-based meta-analyses were calculated using anisotropic effect size signed differential mapping. Nineteen functional neuroimaging studies investigating the processing of negative compared with neutral stimuli in a total of 281 patients with BPD and 293 healthy control subjects (HC) were included. In addition, 10 studies investigating gray matter abnormalities in 263 patients with BPD and 278 HC were analyzed.

RESULTS

Compared with HC, BPD patients showed relatively increased activation of the left amygdala and posterior cingulate cortex, along with blunted responses of the bilateral dorsolateral prefrontal cortex, during the processing of negative emotional stimuli. The multimodal analysis identified the left amygdala to be characterized by a combination of functional hyperactivity and smaller gray matter volume compared with HC. Hyperresponsivity of the amygdala was moderated by medication status of the patient samples. Medication-free samples were characterized by limbic hyperactivity, whereas no such group differences were found in patients currently taking psychotropic medication.

CONCLUSIONS

Results strengthen the assumption that dysfunctional dorsolateral prefrontal and limbic brain regions are a hallmark feature of BPD and therefore are consistent with the conceptualization of BPD as an emotion dysregulation disorder.

Converging Medial Frontal Resting State and Diffusion-Based Abnormalities in Borderline Personality Disorder

BACKGROUND

The psychological profile of patients with borderline personality disorder (BPD), with impulsivity and emotional dysregulation as core symptoms, has guided the search for abnormalities in specific brain areas such as the hippocampal-amygdala complex and the frontomedial cortex. However, whole-brain imaging studies so far have delivered highly heterogeneous results involving different brain locations.

METHODS

Functional resting-state and diffusion magnetic resonance imaging data were acquired in patients with BPD and in an equal number of matched control subjects (n = 60 for resting and n = 43 for diffusion). While mean diffusivity and fractional anisotropy brain images were generated from diffusion data, amplitude of low-frequency fluctuations and global brain connectivity images were used for the first time to evaluate BPD-related brain abnormalities from resting functional acquisitions.

RESULTS

Whole-brain analyses using a p = .05 corrected threshold showed a convergence of alterations in BPD patients in genual and perigenual structures, with frontal white matter fractional anisotropy abnormalities partially encircling areas of increased mean diffusivity and global brain connectivity. Additionally, a cluster of enlarged amplitude of low-frequency fluctuations (high resting activity) was found involving part of the left hippocampus and amygdala. In turn, this cluster showed increased resting functional connectivity with the anterior cingulate.

CONCLUSIONS

With a multimodal approach and without using a priori selected regions, we prove that structural and functional abnormality in BPD involves both temporolimbic and frontomedial structures as well as their connectivity. These structures have been previously related to behavioral and clinical symptoms in patients with BPD.

The aetiological and psychopathological validity of borderline personality disorder in youth: A systematic review and meta-analysis

Controversy surrounds the diagnosis of Borderline Personality Disorder (BPD) in youth. This meta-analysis summarised evidence regarding the aetiological and psychopathological validity of youth BPD (the extent to which youth and adult BPD share common risk factors and psychopathology). We identified 61 studies satisfying predetermined inclusion criteria. Statistically significant pooled associations with youth (19 years of age and under) BPD were observed for sexual abuse (all youth: odds ratio=4.88; 95% confidence interval=3.30, 7.21; children: OR=3.97; 95% CI=1.51, 10.41; adolescents: OR=5.41; 95% CI=3.43, 8.53); physical abuse (all youth: 2.79 [2.03, 3.84]; children: 2.86 [1.98, 4.13]; adolescents: 2.60 [1.38, 4.90]); maternal hostility/verbal abuse (all youth: 3.28 [2.67, 4.03]; children: 3.15 [2.55, 3.88]; adolescents: 4.71 [1.77, 12.53]); and neglect (all youth: 3.40 [2.27, 5.11]; children: 2.87 [1.73, 4.73]; adolescents: 4.87 [2.24, 10.59]). Several psychopathological features were also associated with youth BPD, including comorbid mood (3.21 [2.13, 4.83]), anxiety (2.30 [1.44, 3.70]) and substance use (2.92 [1.60, 5.31]) disorders; self-harm (2.81 [1.61, 4.90]); suicide ideation (all youth: 2.02 [1.23, 3.32]; children: 6.00 [1.81, 19.84]; adolescents: 1.75 [1.20; 2.54]) and suicide attempt (2.10 [1.21, 3.66]). Results demonstrate that adult and youth BPD share common aetiological and psychopathological correlates. This offers some support for the diagnostic validity of youth BPD and indicates the need for clinical recognition in this age group.

Practitioner Review: Borderline personality disorder in adolescence--recent conceptualization, intervention, and implications for clinical practice

BACKGROUND

The past decade has seen an unprecedented increase in research activity on personality disorders (PDs) in adolescents. The increase in research activity, in addition to major nosological systems legitimizing the diagnosis of borderline personality disorder (BPD) in adolescents, highlights the need to communicate new research on adolescent personality problems to practitioners.

SCOPE

In this review, we provide up-to-date information on the phenomenology, prevalence, associated clinical problems, etiology, and intervention for BPD in adolescents. Our aim was to provide a clinically useful practitioner review and to dispel long-held myths about the validity, diagnostic utility, and treatability of PDs in adolescents.

FINDINGS AND CONCLUSION

Alongside providing up-to-date information on the phenomenology, prevalence, and etiology, we also report on associated clinical problems and interventions for adolescent BPD. It is only through early active assessment and identification of youngsters with these problems that a lifetime of personal suffering and health system burden can be reduced or altogether avoided. A variety of evidence-based approaches are now available to treat BPD and related clinical problems in young people. Future research should focus on establishing optimal precision in the diagnostic processes in different treatment settings.

ESCAP Expert Article: borderline personality disorder in adolescence: an expert research review with implications for clinical practice

Borderline personality disorder (BPD) has onset in adolescence, but is typically first diagnosed in young adulthood. This paper provides a narrative review of the current evidence on diagnosis, comorbidity, phenomenology and treatment of BPD in adolescence. Instruments available for diagnosis are reviewed and their strengths and limitations discussed. Having confirmed the robustness of the diagnosis and the potential for its reliable clinical assessment, we then explore current understandings of the mechanisms of the disorder and focus on neurobiological underpinnings and research on psychological mechanisms. Findings are accumulating to suggest that adolescent BPD has an underpinning biology that is similar in some ways to adult BPD but differs in some critical features. Evidence for interventions focuses on psychological therapies. Several encouraging research studies suggest that early effective treatment is possible. Treatment development has just begun, and while adolescent-specific interventions are still in the process of evolution, most existing therapies represent adaptations of adult models to this developmental phase. There is also a significant opportunity for prevention, albeit there are few data to date to support such initiatives. This review emphasizes that there can be no justification for failing to make an early diagnosis of this enduring and pervasive problem.

Recent advances in the developmental aspects of borderline personality disorder

The aim of the current paper was to review the most recent advances in the developmental aspects of borderline personality disorder (BPD) over the last 3 years to highlight the most significant trends in the field. In so doing, we identify and discuss two exciting new trends: (a) an emphasis on the biological basis of adolescent BPD and (b) empirical evidence in support of long-held theories of the development of BPD. Together, these trends suggest that for the first time, empirical findings are beginning to emerge in support of complex and reciprocal biology × environment interactions over time in the development of BPD. We discuss the emerging literature and highlight the translational impact of this work for the assessment and intervention of adolescent BPD.

Specificity of abnormal brain volume in major depressive disorder: a comparison with borderline personality disorder

BACKGROUND

Abnormal brain volume has been frequently demonstrated in major depressive disorder (MDD). It is unclear if these findings are specific for MDD since aberrant brain structure is also present in disorders with depressive comorbidity and affective dysregulation, such as borderline personality disorder (BPD). In this transdiagnostic study, we aimed to investigate if regional brain volume loss differentiates between MDD and BPD. Further, we tested for associations between brain volume and clinical variables within and between diagnostic groups.

METHODS

22 Females with a DSM-IV diagnosis of MDD, 17 females with a DSM-IV diagnosis of BPD and without comorbid posttraumatic stress disorder, and 22 age-matched female healthy controls (HC) were investigated using magnetic resonance imaging. High-resolution structural data were analyzed using voxel-based morphometry.

RESULTS

A significant (p<0.05, cluster-corrected) volume decrease of the anterior cingulate cortex (ACC) was found in MDD compared to HC, as opposed to volume decreases of the amygdala in BPD compared to both HC and MDD. Sensitivity and specificity of regional gray matter volume for a diagnosis of MDD were modest to fair. Amygdala volume was related to depressive symptoms across the entire patient sample.

LIMITATIONS

Potential limitations of this study include the modest sample size and the heterogeneous psychotropic drug treatment.

CONCLUSIONS

ACC volume reduction is more pronounced in MDD with an intermediate degree of volume loss in BPD compared to HC. In contrast, amygdala volume loss is more pronounced in BPD compared to MDD, yet amygdala volume is associated with affective symptom expression in both disorders.

Neurological soft signs in adolescents with borderline personality traits

OBJECTIVE

This study investigated the prevalence and severity of neurological soft signs (NSS), and their relationships with borderline personality (BP) traits in adolescents.

METHODS

Eighty-nine adolescents with BP traits (BP-trait group), and 89 adolescents without traits of any personality disorder (control group), were recruited in China. BP traits were diagnosed by the BPD subscale of the Personality Diagnostic Questionnaire for the DSM-IV (PDQ-4+). The soft sign subscales of the Cambridge Neurological Inventory were administered to all participants. The group differences in prevalence of soft signs and in NSS scores were analyzed, as well as the associations between the NSS scale and borderline personality traits.

RESULTS

Five soft signs were significantly more frequent in adolescents with BP traits. A total of 59.6% of adolescents with BP traits exhibited at least 1 NSS, whereas only 34.8% of adolescents without BP traits did (p < 0.01). A total of 42.7% of adolescents in the BP-trait group exhibited at least 2 NSS, while only 16.9% of adolescents without BP traits did (p < 0.001). Moreover, adolescents with BP traits showed more sensory integration, disinhibition, total neurological soft signs, left-side soft signs, and right-side soft signs, than adolescents without BP traits. Sensory integration and disinhibition were positively associated with BP traits.

CONCLUSION

These findings suggest that adolescents with BP traits may have a nonfocal abnormality of the central nervous system.