A Neurobiological Model of Borderline Personality Disorder: Systematic and Integrative Review

Brain functional abnormality in drug naïve adolescents with borderline personality disorder during self- and other-reflection

A disturbed sense of identity is one of the major features of borderline personality disorder (BPD), which manifests early in the course of the disorder, and is potentially examinable using functional imaging during tasks involving self-reflection. Twenty-seven medication-naïve adolescent female patients with BPD, who had no psychiatric comorbidities, and 28 matched healthy female controls underwent fMRI while answering questions either about themselves or acquaintances. Control conditions consisted of answering questions involving factual knowledge and a low-level baseline (cross fixation). When self-reflection was compared to fact processing, BPD patients exhibited reduced activation in the right dorsolateral prefrontal cortex (DLPFC), as well as in the left parietal and calcarine cortex and the right precuneus. In contrast, other-reflection was associated with relatively lower activation in the medial frontal cortex in BPD patients, with further analysis revealing that this change reflected a failure of de-activation during the fact processing condition. There were no differences between the BPD patients and controls when self- and other-processing was examined against low-level baseline. This study provides evidence of reduced DLPFC activation during self-reflection in adolescent females with BPD, which may reflect diminished top-down cognitive control of this process, but not other-reflection in the 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).

Two sides of the same coin? What neural processing of emotion and rewards can tell us about complex post-traumatic stress disorder and borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) and complex posttraumatic stress disorder (cPTSD) share clinical similarities, complicating diagnosis and treatment. Research on the neurobiology of BPD and monotraumatic PTSD has shown that a prefrontal-limbic imbalance in emotional and reward processing is a hallmark of both disorders, but studies examining this network in cPTSD are lacking. Therefore, this study aimed to directly compare neural processing of emotion and reward during decision making in cPTSD and BPD.

METHODS

Using functional magnetic resonance imaging, we measured neural activity in female patients (27 patients with cPTSD, 21 patients with BPD and 37 healthy controls) during a Desire-Reason Dilemma task featuring distracting fearful facial expressions.

RESULTS

We found no differences in neural activation when comparing cPTSD and BPD. However, when grouping patients based on symptom severity instead on diagnosis, we found that increased symptoms of cPTSD were associated with increased activation of dorsolateral prefrontal cortex during reward rejection, whereas increased symptoms of BPD were associated with decreased activation in prefrontal and limbic regions during reward rejection with distracting negative emotional stimuli.

CONCLUSION

This is the first study to investigate and compare emotional processing and reward-based decision making in cPTSD and BPD. Although we found no neural differences between disorders, we identified symptom-related neural patterns. Specifically, we found that elevated cPTSD symptoms were related to greater sensitivity to reward stimuli, whereas heightened BPD symptoms were related to increased susceptibility to emotional stimuli during goal-directed decision making. These findings enhance our understanding of neural pathomechanisms in trauma-related disorders.

Update on the Neurobiology of Borderline Personality Disorder: A Review of Structural, Resting-State and Task-Based Brain Imaging Studies

PURPOSE OF REVIEW

This review summarizes recent advances in research on the neurobiology of borderline personality disorder (BPD) according to structural brain imaging investigations and resting-state and task-based functional brain activation studies.

RECENT FINDINGS

Extending established findings on differences in regional brain volumes and cortical thickness between BPD and healthy controls, recent research illuminates shared and distinct brain structural characteristics compared to other psychiatric diagnoses, and uncovers relations of these brain structures with transdiagnostic symptoms and clinical features. Resting-state functional brain imaging studies reveal disruptions among adolescents and adults with BPD in frontolimbic and default-mode networks, which primarily underlie affect regulation and self-referential processes, respectively. Recent task-based functional brain imaging research builds on existing neurobiological understanding of emotion and cognition in BPD by revealing novel intersections with interpersonal- and stress-related processes. Studies of psychological and pharmacological interventions suggest possible effects on neural regions underlying emotion processing and behavioral control. Recent advances in neurobiological research on BPD underscore the pathophysiology of affective, behavioral and self-interpersonal symptoms, with growing interest in adolescents with BPD and the impacts of psychological and biological interventions. Corresponding with the increased prominence of alternative dimensional models of personality disorder in recent years, there is a gradual rise in studies examining the relationships of brain structures and functional brain activation with BPD-relevant symptom dimensions, including within transdiagnostic samples.

The Role of Oxytocin and Vasopressin in People with Borderline Personality Disorder: A Closer Look at Adolescents

Borderline personality disorder constitutes a significant medical challenge. Despite the fact that its occurrence among adolescents is currently attracting increasing interest from both clinicians and researchers, there is still insufficient data on this phenomenon. The etiology and maintenance of borderline personality disorder are not yet fully comprehended. Neuropeptides, including oxytocin and vasopressin, are considered to be involved in the development of this condition. The mechanism behind the actions of these neurohormones requires further investigation. Our work aims to collect and analyze the available research and existing hypotheses on the role of oxytocin and vasopressin in people with borderline personality disorder, with special attention drawn to adolescents suffering from this condition.

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.

Impact of Comorbid Personality Disorder on the Risk of Involuntary Hospitalization in Patients Referred for Urgent Forensic Assessment: A Cross-Sectional Study

BACKGROUND/OBJECTIVES

In Belgium, involuntary psychiatric hospitalization is authorized in the presence of certain criteria governed by the law relating to the protection of the mentally ill. The number of involuntary hospitalizations has been increasing continuously in recent years. Since personality disorders are frequent comorbidities in involuntarily hospitalized patients, the aim of this study was to investigate the potential role played by comorbid personality disorders in the decisions about involuntary hospitalization made during urgent forensic assessment.

METHODS

A total of 565 individuals were retrospectively recruited from the database of urgent forensic assessment carried out in the Psychiatric Emergency Department. Logistic regression analyses were performed to investigate the risk of involuntary hospitalization associated with comorbid personality disorders in patients referred for urgent forensic assessment.

RESULTS

66.7% of urgent forensic assessments resulted in involuntary hospitalization. In addition, comorbid personality disorders (especially borderline personality disorder) were associated with a lower risk of involuntary hospitalization in patients referred for urgent forensic assessment.

CONCLUSIONS

In this study, we demonstrated that urgent forensic assessments frequently result in involuntary hospitalizations. Furthermore, this study highlighted that comorbid personality disorders (especially borderline personality disorder) appeared to have a major impact on the decision not to involuntarily hospitalize patients referred for urgent forensic assessment. These elements therefore justify the establishment of adequate clinical reflection to avoid the stigmatization related to these frequent comorbidities in patients at risk of involuntary hospitalization.

Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug

The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.

Components of event-related potentials and borderline personality disorder: a meta-analysis

Background: Borderline personality disorder (BPD) is characterized by symptoms associated with difficulties in emotion regulation, altered self-image, impulsivity, and instability in personal relationships. A relationship has been found between BPD symptoms and altered neuropsychological processes. Studies of event-related potentials (ERP) measured with electroencephalogram (EEG) have found neural correlates related to BPD symptoms. Of note is the P300 component, considered a potential mental health biomarker for trauma-associated disorders. However, no meta-analysis has been found to demonstrate this relationship.Objectives: To evaluate the relationship between the P300 component and BPD symptoms. To evaluate the relationship of other ERP components with BPD symptoms.Methods: The method and procedure were adjusted to the PRISMA checklist. The search was performed in three databases: WOS, Scopus and PubMed. A Random Effects Model was used to perform the analysis of the studies. In addition, a meta-regression was performed with % women, Gini and GDP. Finally, a descriptive analysis of the main results found between P300, other ERP components (LPP, P100 and ERN/Ne) and BPD symptoms was performed.Results: From a review of 485 articles, a meta-analysis was performed with six articles that met the inclusion criteria. A moderate, positive relationship was found between the P300 component and BPD symptoms (REM = .489; p < .001). It was not possible to perform meta-analyses for other ERP components (LPP, P100 and ERN/Ne) due to the low number of articles found.Conclusion: The idea that P300 could be considered for use as a biomarker to identify altered neural correlates in BPD is reinforced. In addition, a moderating effect of inequality (Gini) was detected.

Efficacy and Safety of Aripiprazole in Borderline Personality Disorder: A Systematic Review

Aripiprazole is an atypical antipsychotic medication, and its use in treating borderline personality disorder (BPD) is debatable because it is not FDA-approved for treating BPD. This study aimed to investigate the efficacy and safety of aripiprazole in patients with BPD. On July 2, 2021, the protocol (CRD42021256647) was registered in PROSPERO. PubMed, Scopus, Web of Science, Ovid-Medline, Embase, PsycINFO, and Cochrane (CENTRAL) were searched without regard for language or publication date. We also searched trial registries on ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. Randomized clinical trials with adult patients diagnosed with BPD met the inclusion criteria. The Cochrane risk of bias for randomized trials (RoB-2) method was used to assess the quality of the included studies. We included two previously published randomized clinical trials. There were 76 patients with BPD, with 38, 12, and 26 assigned to the aripiprazole, olanzapine, and placebo groups, respectively. Most patients (88.16%) were females, with ages ranging from 22.1 to 28.14 yr. Aripiprazole has been proven to reduce anxiety, depression, anger, hostility, clinical severity, and obsessive-compulsive behavior, insecurity, melancholy, anxiety, aggressiveness/hostility, phobic anxiety, paranoid thinking, psychoticism, and somatization. The adverse effects were headache, insomnia, restlessness, tremor, and akathisia. The risk of bias was considerable in both trials, which is somewhat problematic considering that prejudice can lead to incorrect outcomes and conclusions. Aripiprazole has demonstrated encouraging outcomes in the treatment of patients with BPD. More randomized controlled studies are needed.

The cultural change narrative as a core component of therapeutic change

Introduction

Research indicates a similar effect of Mentalization-based treatment (MBT) and Dialectical behavior therapy (DBT) for borderline personality disorder (BPD). However, there is a paucity in studies investigating the change narrative received from and developed in these treatments. The aim of the present study is to investigate similarities and differences in the change narratives provided by MBT and DBT, and how these narratives reflect the rationale, explanations, and procedures of the provided treatment.

Methods

The study is a qualitative analysis of seven interviews conducted by the authors. Three of the participants had received MBT, and four of the participants had received DBT. This study presents an Interpretative Phenomenological Analysis (IPA) of the change narratives received in two specialized treatments for BPD.

Results

The main findings from the IPA were that the change narratives described by the participants reflected the treatment they received. The DBT participants highlighted explicit learning of tools and techniques, with predictable and safe therapists. In contrast, the MBT participants emphasized a long-lasting process of exploring to create procedural learning with therapists who followed their lead.

Discussion

The participants' stories of change shed light on how a change narrative was developed, and therefore how the rationale, explanations and procedures were conveyed differently by MBT and DBT.

Antidepressant emergent mood switch in major depressive disorder: onset, clinical correlates and impact on suicidality

Antidepressant (AD)- emergent mood switch (AEMS) is a common complication of bipolar depression. This study aimed to investigate the prevalence and clinical correlates of subthreshold AEMS (i.e. not fulfilling DSM criteria for hypomanic episodes) in major depressive disorder (MDD) and, prognostically, its impact on AD treatment outcome and suicidality. The study involved 425 outpatients with MDD followed during the acute phase (12 weeks) and continuation (weeks 13-28) AD treatment. AEMS was assessed through the Altman Self-Rating Mania scale (ASRM ≥ 6). Several clinical features differentiated individuals with or without subthreshold AEMS (n = 204 vs. 221): negative self-perception [odds ratio (OR) 1.017-1.565]; panic disorder (OR 1.000-1.091); subthreshold hypomanic episodes (OR 1.466-13.352); childhood emotional abuse (OR 1.053-2.447); lifetime suicidal behaviour (OR 1.027-1.236); AD-related remission (χ 2  = 22.903 P  < 0.0001) and suicide ideation (χ 2  = 16.701 P  < 0.0001). In AEMS earlier onset showed a strong correlation with bipolar spectrum disorder (overall score: P  = 0.0053; mixed depression: P  = 0.0154; subthreshold hypomania: P  = 0.0150) whereas late-onset was associated with more severe suicidal behaviour ( P  < 0.001). In conclusion, our results demonstrate that subthreshold mood switches occur frequently in unipolar depression during acute AD treatment as well as in continuation phase. Time of switch onset seems to have the greatest diagnostic and prognostic value.

Neurocognition of females with substance use disorder and comorbid personality disorder: Divergence in subjective and objective cognition

At least one in four patients with substance use disorder (SUD) meet criteria for personality disorder and overlapping neurocognitive deficits may reflect shared neurobiological mechanisms. We studied neurocognition in females attending residential SUD treatment by comparing SUD with (n = 20) or without (n = 30) comorbid personality disorder. Neuropsychological testing included working memory, inhibition, shifting, verbal fluency, design fluency, psychomotor speed, immediate and delayed verbal memory, processing speed, premorbid functioning, cognitive screening, and self-reported executive function. As expected, whole-sample deficits included working memory (d = -.91), self-reported executive function (d = -.87), processing speed (d = -.40), delayed verbal memory recall (d = -.39), premorbid functioning (d = -.51), and cognitive screening performance (d = -.61). Importantly, the comorbid personality disorder group showed greater self-reported executive dysfunction (d = -.67) and poorer shifting performance (d = -.65). However, they also evidenced better working memory (d = .84), immediate (d = .95) and delayed (d = .83) verbal memory, premorbid functioning (d = .90), and cognitive screening performance (d = .77). Overall executive dysfunction deficits were concordant with those observed in previous SUD studies. Surprisingly, comorbid personality disorder was associated with a pattern indicating poorer subjective (self-report) but better objective performance on a number of tasks, apart from shifting deficits that may relate to emotion dysregulation. Subjective emotional dysfunction may influence the cognitive deficits observed in the personality disorder group.

[Towards a pragmatic cohabitation of theoretical and clinical models: The example of "Good Psychiatric Management" in the treatment of borderline personality disorder]

Borderline personality disorder (BPD) is a common disorder in general and clinical populations and is related to potentially severe medical and socio-professional consequences. Treatment of BPD is based on evidence-based psychotherapies (such as Dialectical Behavioral Therapy, Mentalization-Based Therapy, Schema-Focused Therapy or Transference Focused Psychotherapy), which have been shown effective but are poorly available in France. Pharmacological treatments, which are more easily available, are not effective in treating symptoms of the disorder but can be useful in management of comorbidities. In this context, recently called "generalist" models have been developed, which every well-trained psychiatrist can implement in their daily practice, combining practical elements from evidence-based psychotherapies and elements of pharmacological management of symptoms and comorbidities. The purpose of this article is to present one of these models, the Good Psychiatric Management (GPM) and its basic principles and its applications, and to provide one of the first French-speaking resources about this model. In addition, beyond the practical elements proposed by the GPM, we discuss the deeper question that it raises, namely the question of a pragmatic integration of different theoretical and clinical models. Indeed, the treatment of BPD patients is at the junction of different conceptualizations of mental pathology (psychopathological, neurobiological) and different modalities of practice (psychotherapy, biological psychiatry). In a French context, that sometimes separates these two models, and in our opinion GPM constitutes an example of clinical collaboration which shows the interest of the combined role of psychiatrist-psychotherapist.

Brain functional abnormality in drug treated and drug naïve adolescents with borderline personality disorder: Evidence for default mode network dysfunction

BACKGROUND

Patients with borderline personality disorder (BPD) have been found to show functional brain abnormality, including in the medial frontal cortex and other areas of the default mode network (DMN). The current study aimed to examine activations and de-activations in drug treated and medication-free female adolescents with the disorder.

METHODS

39 DSM-5 adolescent female patients with BPD without psychiatric comorbidity and 31 matched healthy female adolescents underwent fMRI during the performance of 1-back and 2-back versions of the n-back working memory task. Linear models were used to obtain maps of within-group activations and de-activations and areas of differences between the groups.

RESULTS

On corrected whole-brain analysis, the BPD patients showed failure to de-activate a region of the medial frontal cortex in the 2-back > 1-back comparison. The 30 never-medicated patients additionally showed a failure to de-activate the right hippocampus in the 2-back versus baseline contrast.

CONCLUSIONS

Evidence of DMN dysfunction was observed in adolescent patients with BPD. Because the relevant medial frontal and hippocampal changes were seen in unmedicated young patients without comorbidity, they might be considered intrinsic to the disorder.

Dimensional personality impairment is associated with disruptions in intrinsic intralimbic functional connectivity

BACKGROUND

Recently proposed alternative dimensional models of personality disorder (PD) place the severity of impairments in self and interpersonal functioning at the core of personality pathology. However, associations of these impairments with disturbances in social, cognitive, and affective brain networks remain uninvestigated.

METHODS

The present study examined patterns of resting-state functional connectivity (rsFC) in a sample of 74 age- and sex-matched participants (45 inpatients with PD and 29 healthy controls). At a minimum, PD patients carried a diagnosis of borderline PD, although the majority of the sample had one or more additional PDs. rsFC patterns in the following networks were compared between groups and in association with dimensional personality impairments: default mode network (DMN)/core mentalization, frontolimbic, salience, and central executive. Further, the extent to which variation in rsFC was explained by levels of personality impairment as compared to typology-specific borderline PD symptom severity was explored.

RESULTS

Relative to controls, the PD group showed disruptions in rsFC within the DMN/core mentalization and frontolimbic networks. Among PD patients, greater severity of dimensional self-interpersonal impairment was associated with stronger intralimbic rsFC. In contrast, severity of borderline PD-specific typology was not associated with any rsFC patterns.

CONCLUSIONS

Disruptions in core mentalization and affective networks are present in PD. Higher intralimbic functional connectivity may underlie self-interpersonal personality impairment in PD regardless of diagnostic typology-specific PD symptoms, providing initial neurobiological evidence supporting alternative dimensional conceptualizations of personality pathology.

Accelerated epigenetic aging in women with emotionally unstable personality disorder and a history of suicide attempts

Emotional unstable personality disorder (EUPD; previously borderline personality disorder, BPD) is associated with excess natural-cause mortality, comorbid medical conditions, poor health habits and stress related epigenomic alterations. Previous studies demonstrated that GrimAge - a state-of-the-art epigenetic age (EA) estimator - strongly predicts mortality risk and physiological dysregulation. Herein, we utilize the GrimAge algorithm to investigate whether women with EUPD and a history of recent suicide attempts exhibit EA acceleration (EAA) in comparison to healthy controls. Genome-wide methylation patterns were measured using the Illumina Infinum Methylation Epic BeadChip in whole blood from 97 EUPD patients and 32 healthy controls. The control group was significantly older (p < 0.0001) and reported lesser exposure to violent behavior in both youth and adulthood (p < 0.0001). Groups were otherwise comparable regarding gender, BMI, or tobacco usage (p > 0.05). EA estimator DNAmGrimAge exceeded chronological age by 8.8 and 2.3 years in the EUPD and control group, respectively. Similarly, EAA marker AgeAccelGrim was substantially higher in EUPD subjects when compared to controls, in both univariate and multivariate analyzes (p < 0.00001). Tobacco usage conferred substantial within-group effects on the EA-chronological age difference, i.e., 10.74 years (SD = 4.19) compared to 6.00 years (SD = 3.10) in the non-user EUPD group (p < 0.00001). Notably, past alcohol and substance abuse, use of psychotropic medications, global assessment of functioning, self-reported exposure to violent behavior in youth and adulthood, later completed suicide (N = 8) and age at first suicide attempt did not predict EAA in the EUPD group (p > 0.05). These results underscore the importance of addressing medical health conditions along with low-cost preventative interventions aimed at improving somatic health outcomes in EUPD, such as efforts to support cessation of tobacco use. The independency of GrimAge to other EA algorithms in this group of severely impaired EUPD patients, suggest it may have unique characteristics to evaluate risk of adverse health outcomes in context of psychiatric disorders.

Pathophysiological aspects of complex PTSD - a neurobiological account in comparison to classic posttraumatic stress disorder and borderline personality disorder

Despite a great diagnostic overlap, complex posttraumatic stress disorder (CPTSD) has been recognised by the ICD-11 as a new, discrete entity and recent empirical evidence points towards a distinction from simple posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD). The development and maintenance of these disorders is sustained by neurobiological alterations and studies using functional magnetic resonance imaging (fMRI) may further contribute to a clear differentiation of CPTSD, PTSD and BPD. However, there are no existing fMRI studies directly comparing CPTSD, PTSD and BPD. In addition to a summarization of diagnostic differences and similarities, the current review aims to provide a qualitative comparison of neuroimaging findings on affective, attentional and memory processing in CPTSD, PTSD and BPD. Our narrative review alludes to an imbalance in limbic-frontal brain networks, which may be partially trans-diagnostically linked to the degree of trauma symptoms and their expression. Thus, CPTSD, PTSD and BPD may underlie a continuum where similar brain regions are involved but the direction of activation may constitute its distinct symptom expression. The neuronal alterations across these disorders may conceivably be better understood along a symptom-based continuum underlying CPTSD, PTSD and BPD. Further research is needed to amend for the heterogeneity in experimental paradigms and sample criteria.

Increased Methylation of Brain-Derived Neurotrophic Factor (BDNF) Is Related to Emotionally Unstable Personality Disorder and Severity of Suicide Attempt in Women

Brain-derived neurotrophic factor (BDNF) has previously been associated with the pathogenesis of both emotionally unstable personality disorder (EUPD) and suicidal behavior. No study has yet investigated BDNF-associated epigenetic alterations in a group of severely impaired EUPD and suicidal patients. The discovery cohort consisted of 97 women with emotionally unstable personality disorder (EUPD) with at least two serious suicide attempts (SAs) and 32 healthy female controls. The genome-wide methylation pattern was measured by the Illumina EPIC BeadChip and analyzed by robust linear regression models to investigate mean BDNF methylation levels in a targeted analysis conditioned upon severity of suicide attempt. The validation cohort encompassed 60 female suicide attempters, stratified into low- (n = 45) and high-risk groups (n = 15) based on degree of intent-to-die and lethality of SA method, and occurrence of death-by-suicide at follow-up. Mean BDNF methylation levels exhibited increased methylation in relation to EUPD (p = 0.0159, percentage mean group difference ~3.8%). Similarly, this locus was confirmed as higher-methylated in an independent cohort of females with severe suicidal behavior (p = 0.0300). Results were independent of age and BMI. This is the first study to reveal emerging evidence of epigenetic dysregulation of BDNF with dependence on features known to confer increased risk of suicide deaths (lethality of suicide-attempt method and presence of EUPD diagnosis with history of recent SAs). Further studies investigating epigenetic and genetic effects of BDNF on severe suicidal behavior and EUPD are needed to further elucidate the role of epigenetic regulatory mechanisms and neurotrophic factors in relation to suicide and EUPD, and hold potential to result in novel treatment methods.

Improving treatment outcomes for borderline personality disorder: what can we learn from biomarker studies of psychotherapy?

PURPOSE OF REVIEW

Borderline personality disorder (BPD) is a severe and common psychiatric disorder and though evidence-based psychotherapies are effective, rates of treatment nonresponse are as high as 50%. Treatment studies may benefit from interdisciplinary approaches from neuroscience and genetics research that could generate novel insights into treatment mechanisms and tailoring interventions to the individual.

RECENT FINDINGS

We provide a timely update to the small but growing body of literature investigating neurobiological and epigenetic changes and using biomarkers to predict outcomes from evidence-based psychotherapies for BPD. Using a rapid review methodology, we identified eight new studies, updating our earlier 2018 systematic review. Across all studies, neuroimaging ( n  = 18) and genetics studies ( n  = 4) provide data from 735 participants diagnosed with BPD (mean sample size across studies = 33.4, range 2-115).

SUMMARY

We report further evidence for psychotherapy-related alterations of neural activation and connectivity in regions and networks relating to executive control, emotion regulation, and self/interpersonal functioning in BPD. Emerging evidence also shows epigenetic changes following treatment. Future large-scale multisite studies may help to delineate multilevel treatment targets to inform intervention design, selection, and monitoring for the individual patient via integration of knowledge generated through clinical, neuroscience, and genetics research.

Hyperreactivity and Impaired Habituation of Startle Amplitude During Unpleasant Pictures in Borderline but Not Schizotypal Personality Disorder: Quantifying Emotion Dysregulation

BACKGROUND

Borderline personality disorder (BPD) is characterized by greater intensity of reactions to unpleasant emotional cues and a slower-than-normal return of these responses to baseline. Habituation is defined as decreased response to repeated stimulation. Affect-modulated startle (AMS), a translational psychophysiological approach, is mediated by the amygdala and used to study emotion processing in both humans and animals. This is the first study to examine the specificity of habituation anomalies in BPD during passive emotional and neutral picture processing.

METHODS

A total of 90 participants were studied: patients with BPD (n = 35), patients with schizotypal personality disorder (n = 26; included as a psychopathological comparison group), and healthy control subjects (n = 29). Participants received rigorous clinical assessments, and patients were unmedicated. AMS was examined during a series of intermixed unpleasant, neutral, and pleasant pictures.

RESULTS

Compared with the other groups, patients with BPD showed greater overall AMS during unpleasant pictures and prolonged habituation of startle amplitude during unpleasant pictures from early to later trials. The groups did not differ in AMS during neutral or pleasant pictures or self-reported picture valence. Among the patients with BPD, prolonged habituation to unpleasant pictures was associated with greater symptom severity and suicidal/self-harming behavior.

CONCLUSIONS

These findings 1) indicate that abnormal processing of and habituation to unpleasant pictures is observed in BPD but not schizotypal personality disorder, suggesting that these deficits are not simply characteristics of personality disorders in general; 2) are consistent with studies showing deficient amygdala habituation to unpleasant pictures in BPD; and 3) have significant implications for clinical assessment and treatment of BPD, e.g., alternative therapies for BPD such as gradual exposure to unpleasant emotional stimuli or amygdala neurofeedback may aid habituation deficits.

Executive functioning in adults with borderline personality disorder and first-degree biological relatives

OBJECTIVES

Behavioural dysregulation is a heritable core symptom domain in borderline personality disorder (BPD) that is likely influenced by the integrity of executive functions (EFs). However, the extent to which familial risk for BPD confers decrement to EFs has yet to be comprehensively studied.

METHODS

In this family study, probands with BPD (n = 73), first-degree biological relatives (n = 65), and healthy controls without psychiatric diagnoses (n = 77) were assessed in abstraction, attentional vigilance, working memory, cognitive flexibility, interference resolution, planning, problem solving, and response inhibition.

RESULTS

In univariate analyses, probands demonstrated lower response inhibition than relatives. Comparatively, discriminant function analyses revealed that lower interference resolution and response inhibition jointly discriminated probands from relatives and controls, whereas a combination of less efficient problem solving and difficulty manipulating mental information discriminated probands and relatives from controls. Moreover, the subset of psychiatrically non-affected relatives demonstrated a pattern of resilience to psychiatric morbidity substantiated by stronger response inhibition and abstraction abilities despite less efficient problem solving.

CONCLUSIONS

Familial risk for BPD is represented predominantly by a pattern of problem-solving and working memory deficits. Resilience to a psychiatric disorder in non-affected relatives reflects both EF weaknesses and strengths, highlighting potential protective factors that should be considered in future neurocognitive research on BPD families.

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.

Neurophysiological biomarkers of response inhibition and the familial risk for borderline personality disorder

Understanding of the biological factors that run in families affected with borderline personality disorder (BPD) is limited. The authors investigated the familial aggregation of neurophysiological biomarkers of response inhibition in the first-degree biological relatives of probands with BPD and associations with psychiatric diagnosis and impulsive traits. In the present study, psychiatric diagnoses and impulsive traits were measured in BPD probands (n = 86), psychiatrically affected and non-affected relatives (n = 60) and controls (n = 83). While undergoing neuroimaging using functional near-infrared spectroscopy, prefrontal cortex (PFC) activation was measured during a go/no-go response inhibition task and compared between probands, relatives and controls. Additionally, non-psychiatrically affected relatives and controls were contrasted to examine the potential impact of familial risk for BPD on response inhibition-related PFC activation in the absence of confounding psychiatric morbidity. Probands showed bilateral decreases in PFC activation during response inhibition compared to relatives and controls. Conversely, both affected and non-affected relatives displayed higher activation than controls and probands in left lateral/medial and right medial PFC, although non-affected relatives showed a lesser extent of activation than affected relatives. Probands and controls reporting greater impulsive traits displayed deactivation across the PFC during response inhibition, whereas relatives showed increased activation. In this first family study of neuroimaging biomarkers in BPD, we show that the familial risk for BPD is reflected in activation of the PFC during response inhibition, with lifetime psychiatric diagnosis and higher impulsive traits in relatives associated with larger increases in PFC activity. Higher PFC activity during response inhibition including among non-affected relatives could reflect a neurophysiological compensatory mechanism.

Borderline personality disorder and its symptom clusters: A review of positron emission tomography and single photon emission computed tomography studies

Positron emission tomography (PET) and single photon emission computed tomography (SPECT) are two neuroimaging techniques that have led to important insights into the pathophysiology of borderline personality disorder (BPD) and its symptom clusters. This paper provides the most up-to-date review of PET and SPECT studies targeting BPD. A systematic search of PET and SPECT studies using the databases PsycINFO, PubMed, and Embase was implemented, which yielded 30 articles in the end. Earlier PET studies largely reported decreased glucose metabolism in prefrontal brain regions. More recent PET research has pointed to alterations in monoaminergic systems, greater activation of the opioid system during sadness induction, as well as abnormalities of the brain endocannabinoid system in BPD. SPECT studies of BPD mainly identified changes in regional cerebral blood flow and alterations of the serotonergic system. Such PET and SPECT study abnormalities have been suggested to relate to the symptomatology of BPD, including impulsivity, aggression, and mood changes. The implications of these neuroimaging studies in terms of shedding new light on the pathophysiology of BPD and providing new avenues for drug development are discussed.

Fronto-limbic neural variability as a transdiagnostic correlate of emotion dysregulation

Emotion dysregulation is central to the development and maintenance of psychopathology, and is common across many psychiatric disorders. Neurobiological models of emotion dysregulation involve the fronto-limbic brain network, including in particular the amygdala and prefrontal cortex (PFC). Neural variability has recently been suggested as an index of cognitive flexibility. We hypothesized that within-subject neural variability in the fronto-limbic network would be related to inter-individual variation in emotion dysregulation in the context of low affective control. In a multi-site cohort (N = 166, 93 females) of healthy individuals and individuals with emotional dysregulation (attention deficit/hyperactivity disorder (ADHD), bipolar disorder (BD), and borderline personality disorder (BPD)), we applied partial least squares (PLS), a multivariate data-driven technique, to derive latent components yielding maximal covariance between blood-oxygen level-dependent (BOLD) signal variability at rest and emotion dysregulation, as expressed by affective lability, depression and mania scores. PLS revealed one significant latent component (r = 0.62, p = 0.044), whereby greater emotion dysregulation was associated with increased neural variability in the amygdala, hippocampus, ventromedial, dorsomedial and dorsolateral PFC, insula and motor cortex, and decreased neural variability in occipital regions. This spatial pattern bears a striking resemblance to the fronto-limbic network, which is thought to subserve emotion regulation, and is impaired in individuals with ADHD, BD, and BPD. Our work supports emotion dysregulation as a transdiagnostic dimension with neurobiological underpinnings that transcend diagnostic boundaries, and adds evidence to neural variability being a relevant proxy of neural efficiency.

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.

Anomalous Amygdala Habituation to Unpleasant Stimuli Among Unmedicated Individuals With Borderline Personality Disorder and a History of Self-Harming Behavior

Self-harming behavior (SB) is one of the diagnostic criteria for borderline personality disorder (BPD). However, it is not exhibited by all individuals with BPD. Furthermore, studies examining the neural correlates of SB in BPD are lacking. Given research showing that BPD patients have difficulty habituating to affective stimuli, this study investigated whether anomalous amygdala activation is specific to BPD patients with SB. The authors used fMRI to compare amygdala activation in BPD patients with SB (n = 15) to BPD patients without SB (n = 18) and healthy controls (n = 32) during a task involving pleasant, neutral, and unpleasant pictures, presented twice. BPD patients with SB demonstrated greater amygdala activity during the second presentation of unpleasant pictures. Results highlight neurobiological differences in BPD patients with and without SB and suggest that anomalous amygdala habituation to unpleasant stimuli may be related to SB.

Diffusion tensor imaging of corpus callosum in adolescent females with borderline personality disorder

OBJECTIVES

The aim of this study was to assess the structural alteration of corpus callosum (CC) in adolescent females with Borderline Personality Disorder (BPD) and detect the relationship between these changes and BPD symptoms.

METHODS

A comparative case control study was conducted on 50 adolescent females that were divided into 2 groups; 25 outpatients suffering from BPD (according to DSM-IV-TR diagnostic criteria) compared to 25 healthy adolescents. All subjects were assessed by Borderline Personality Questionnaire, Barratt impulsivity scale-11, Brief Non-Suicidal Self-Injury Assessment tool, Beck Scale for Suicidal Ideation, and Diffusion tensor imaging.

RESULTS

Relative to control subjects, BPD patients had significantly lower fractional anisotropy (FA) values in the genu and lower mean diffusivity (MD) values in the body of CC. There was a negative correlation between FA values in the genu and body of CC and impulsivity. MD in the body of CC was positively correlated with motor impulsiveness and negatively correlated with suicidality.

CONCLUSION

Adolescent females with BPD show structural alterations in the CC that are related to symptoms of emotional dysregulation and impulsivity.

TFP Extended: Development and Recent Advances

Recent advances in the understanding of personality pathology have contributed to an emphasis on the core of personality pathology as deficits in self-functioning and interpersonal functioning at different levels of severity that must be assessed for clinical intervention. In concert with these conceptual and empirical advances, transference-focused psychotherapy (TFP), an empirically supported psychodynamic treatment for borderline personality disorder, has been in constant development with extensive clinical use. This article describes an object relations model for conceptualizing and assessing levels of personality organization, a transdiagnostic approach to personality pathology, and related treatment modifications, thus expanding the utilization of TFP beyond borderline personality disorder to the full range of personality dysfunction. The core of this treatment approach is a sequential interpretive process between patient and therapist. This process takes place within the context of a structured treatment frame tailored to the unique individual with problems in self-functioning and interpersonal functioning in his/her particular environment.

Facial Emotion Perception in Borderline Personality Disorder: Differential Neural Activation to Ambiguous and Threatening Expressions and Links to Impairments in Self and Interpersonal Functioning

BACKGROUND

Many individuals with borderline personality disorder (BPD) perceive emotional expressions in faces intended to convey no emotion and display a heightened sensitivity to facial expressions conveying threat, such as fear. In BPD, the amygdala activates in response to ambiguous and threatening facial expressions, although the differential sensitivity of this brain region to higher and lower intensities of fearful expressions and the relationship of this neural activity to personality impairments have not yet been investigated.

METHODS

In the present study, we examined brain activation during an implicit facial emotion task with neutral faces and fearful expressions displayed at 50% and 100% intensity in patients with BPD (n=45) and healthy controls (HC; n=25).

RESULTS

On neutral faces, higher brain activation was found in BPD compared to HC in the right temporal pole, amygdala, hippocampus, pallidum, and orbitofrontal cortex, whereas no significant whole-brain group differences were observed for either intensity of fearful expressions. A region-of-interest analysis focused on the amygdala-hippocampal complex showed greater activation for neutral and 50%-intensity fearful faces in BPD. Severity of personality impairment in the domains of empathy and identity were associated with higher precuneus activity during neutral and 100%-fearful face processing.

LIMITATIONS

Brain activation differences of this naturalistic severely ill inpatient sample may be influenced by comorbid Axis-I disorders often seen in samples of BPD.

CONCLUSIONS

These findings suggest a heightened amygdala-hippocampal response to neutral faces and moderate-intensity fearful expressions in BPD, while self and interpersonal impairments are associated with task-based activations in regions implicated in self-referential processes.

Neural Changes in Borderline Personality Disorder After Dialectical Behavior Therapy-A Review

The biological component of the biosocial theory of emotion regulation stipulates that borderline personality disorder (BPD) arises from biological vulnerabilities to heightened emotional reactivity. Comprehensive reviews have consistently implicated abnormalities in the amygdala, anterior cingulate cortex, and hippocampus in the neurobiology of BPD. While Dialectical Behavior Therapy (DBT) is the leading evidence-based psychotherapy for the treatment of BPD, there remains a paucity of literature examining changes in the neurobiology of BPD following DBT treatment. Nine studies were identified that examined neurobiological changes in BPD after the completion of DBT. Results indicated that there was significant deactivation of amygdala activity as well as the anterior cingulate cortex in patients with BPD after DBT treatment. As well, several studies found after DBT treatment, BPD patients had a decreased activity in the inferior frontal gyrus in response to arousing stimuli and increased activity in response to inhibitory control. Future research on the neurobiological change after DBT treatment can help clarify biological mechanisms of change in BPD.

Risk and Protective Factors for Personality Disorders: An Umbrella Review of Published Meta-Analyses of Case-Control and Cohort Studies

The putative risk/protective factors for several personality disorders remain unclear. The vast majority of published studies has assessed personality characteristics/traits rather than disorders. Thus, the current umbrella review of meta-analyses (MAs) aims to systematically assess risk or protective factors associated with personality disorders. We searched PubMed-MEDLINE/PsycInfo databases, up to August 31, 2020. Quality of MAs was assessed with AMSTAR-2, while the credibility of evidence for each association was assessed through standard quantitative criteria. Out of 571 initial references, five meta-analyses met inclusion criteria, encompassing 56 associations of 26 potential environmental factors for antisocial, dependent, borderline personality disorder, with a median of five studies per association, and median 214 cases per association. Overall, 35 (62.5%) of the associations were nominally significant. Six associations met class II (i.e., highly suggestive) evidence for borderline personality disorder, with large effect sizes involving childhood emotional abuse (OR = 28.15, 95% CI 14.76-53.68), childhood emotional neglect (OR = 22.86, 95% CI 11.55-45.22), childhood any adversities (OR = 14.32, 95% CI 10.80-18.98), childhood physical abuse (OR = 9.30, 95% CI 6.57-13.17), childhood sexual abuse (OR = 7.95, 95% CI 6.21-10.17), and childhood physical neglect (OR = 5.73, 95% CI 3.21-10.21), plus 16 further associations supported by class IV evidence. No risk factor for antisocial or dependent personality disorder was supported by class I, II, and III, but six and seven met class IV evidence, respectively. Quality of included meta-analyses was rated as moderate in two, critically low in three. The large effect sizes found for a broad range of childhood adversities suggest that prevention of personality disorders should target childhood-related risk factors. However, larger cohort studies assessing multidimensional risk factors are needed in the field.

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.

The Relationship between Maternal Personality Disorder and Early Birth Outcomes: A Systematic Review and Meta-Analysis

(1) Background: Women with personality disorder are at risk of social and emotional problems which impact deleteriously on everyday functioning. Moreover, a personality disorder diagnosis has been established to have an adverse impact upon pregnancy outcomes and child health. Understanding this impact is critical to improving both maternal and child outcomes. This systematic review and meta-analysis will evaluate the contemporary evidence regarding these relationships. (2) Methods: Prospero and Cochrane were searched for any systematic reviews already completed on this topic. Academic Search Premier, CINAHL Complete, MEDLINE, PsycARTICLES, PsycINFO via the EBSCO host, and the Web of Science Core Collection were searched to include research articles published between 1980 and 2019. A total of 158 records were identified; 105 records were screened by reviewing the abstract; 99 records were excluded; 6 full text articles were assessed for eligibility; 5 records were included in the review. (3) Results: All the included studies reported on preterm birth. The meta-analysis indicates significant risk of preterm birth in women with personality disorder (overall odds ratio (OR) 2.62; CI 2.24–3.06; p < 0.01). Three studies reported on low birth weight, with the meta-analysis indicating a raised risk of low birth weight of the babies born to women with personality disorder (overall OR 2.00 CI 1.12–3.57 (p = 0.02)). Three studies reported on appearance, pulse, grimace, activity, and respiration (APGAR) score, with the meta-analysis of OR’s indicating a risk of low APGAR score in women with personality disorder (overall OR 2.31; CI 1.17–4.55; p = 0.02). (4) Conclusions: The infants of women with personality disorder are at elevated risk of preterm birth, low birth weight and low APGAR score.

A randomized controlled trial comparing the clinical efficacy and cost-effectiveness of eye movement desensitization and reprocessing (EMDR) and integrated EMDR-Dialectical Behavioural Therapy (DBT) in the treatment of patients with post-traumatic stress disorder and comorbid (Sub)clinical borderline personality disorder: study design

BACKGROUND

Comorbidity between Posttraumatic Stress Disorder (PTSD) and Borderline Personality Disorder (BPD) is high. There is growing motivation among clinicians to offer PTSD treatments - such as Eye Movement Desensitization and Reprocessing (EMDR) - to patients with PTSD and comorbid BPD. However, a large subgroup with comorbid BPD does not sufficiently respond to PTSD treatment and is more likely to be excluded or to dropout from treatment. Dialectical Behaviour Therapy (DBT) for BPD is well established and although there is some evidence that DBT combined with DBT Prolonged Exposure (DBT + DBT PE) is twice as effective in reducing PTSD symptoms than DBT alone, the comparative efficacy of integrated PTSD-DBT and PTSD-only treatment has not been investigated yet. The current study will therefore evaluate the comparative clinical efficacy and cost-effectiveness of EMDR-DBT and EMDR-only in patients with PTSD and comorbid (sub)clinical BPD. Moreover, it is not clear yet what treatment works best for which individual patient. The current study will therefore evaluate neurobiological predictors and mediators of the individual response to treatment.

METHOD

A randomized controlled trial comparing the clinical efficacy and cost-effectiveness of integrated EMDR-DBT (n = 63) and EMDR-only (n = 63) in treatment-seeking adult patients with PTSD and comorbid (sub)clinical BPD. In addition, neurobiological predictors and mediators of treatment outcome, such as hair cortisol, FKBP5 and BDNF protein levels and FKBP5 and BDNF methylation status, are measured through hair and blood samples.

DISCUSSION

This is the first study to compare the clinical efficacy and cost-effectiveness of integrated EMDR-DBT and EMDR-only in patients with PTSD and comorbid (sub)clinical BPD, while simultaneously identifying individual predictors and mediators of treatment response. Results will reveal which treatment works best for which individual patient, thereby guiding individual treatment choices and personalizing psychiatry.

TRIAL REGISTRATION

Clinical Trials, NCT03833453 . Retrospectively registered, 15 March 2019.

Diffusion tensor imaging in borderline personality disorder showing prefrontal white matter alterations

Borderline personality disorder (BPD) has repeatedly been linked to alterations in fronto-limbic dysfunction. In this study, we tested the hypothesis of disturbed structural connectivity in underlying fibre tracts and their relation to symptom profiles. We analysed diffusion tensor imaging (DTI) data from 18 female BPD patients and 38 female healthy controls. Group comparisons showed significant (p < .05, FDR adjusted) increase of radial diffusivity (RD) in the right frontal lobe, including the uncinate fasciculus, anterior thalamic radiation, and inferior fronto-occipital fasciculus, as well as overall apparent diffusion coefficient (ADC) increases in the anterior and posterior internal capsule. Symptom correlations, based on the BSL-95 questionnaires, within the BPD sample showed significant negative correlations of dysphoria with ADC the left and right anterior thalamic radiation, and positive correlations of fractional anisotropy with self-perception scores in the right superior corona radiata. While our findings add to the fronto-limbic dysfunction model of BPD, they provide additional evidence of links to its affective core pathology, particularly frontotemporal and fronto-thalamic systems.

A Meta-analysis and Systematic Review of Emotion-Regulation Strategies in Borderline Personality Disorder

Emotion dysregulation is often considered a core characteristic of individuals with borderline personality disorder (BPD). With the development and strength of a contemporary affective-science model that encompasses both healthy emotion regulation (ER) and emotion dysregulation, this model has increasingly been used to understand the affective experiences of people with BPD. In this meta-analysis and review, we systematically review six of the most commonly studied ER strategies and determine their relative endorsement in individuals with elevated symptoms of BPD compared to individuals with low symptoms of BPD and healthy controls, as well as to individuals with other mental disorders. Results from 93 unique studies and 213 different effect-size estimates indicated that symptoms of BPD were associated with less frequent use of ER strategies that would be considered more effective at reducing negative affect (i.e., cognitive reappraisal, problem solving, and acceptance) and more frequent use of ER strategies considered less effective at reducing negative affect (i.e., suppression, rumination, and avoidance). When compared to individuals with other mental disorders, people with BPD endorsed higher rates of rumination and avoidance, and lower rates of problem solving and acceptance. We also review important contributions from studies of ER in BPD that we were unable to incorporate into our meta-analysis. We conclude by discussing how the pattern of using ER strategies in BPD contributes to emotion dysregulation and also the potential reasons for this pattern, integrating both Gross's extended process model of ER and Linehan's updated theoretical account on the development of emotion dysregulation.

Cortical haemodynamic response measured by functional near infrared spectroscopy during a verbal fluency task in patients with major depression and borderline personality disorder

BACKGROUND

Functional near infrared spectroscopy (fNIRS) provides a direct and quantitative assessment of cortical haemodynamic function during a cognitive task. This functional neuroimaging modality may be used to elucidate the pathophysiology of psychiatric disorders, and identify neurophysiological differences between co-occurring psychiatric disorders. However, fNIRS research on borderline personality disorder (BPD) has been limited. Hence, this study aimed to compare cerebral haemodynamic function in healthy controls (HC), patients with major depressive disorder (MDD) and patients with BPD.

METHODS

fNIRS signals during a verbal fluency task designed for clinical assessment was recorded for all participants. Demographics, clinical history and symptom severity were also noted.

FINDINGS

Compared to HCs (n = 31), both patient groups (MDD, n = 31; BPD, n = 31) displayed diminished haemodynamic response in the frontal, temporal and parietal cortices. Moreover, haemodynamic response in the right frontal cortex is markedly lower in patients with MDD compared to patients with BPD.

INTERPRETATION

Normal cortical function in patients with BPD is disrupted, but not as extensively as in patients with MDD. These results provide further neurophysiological evidence for the distinction of patients with MDD from patients with BPD.

Atypical processing of social anticipation and feedback in borderline personality disorder

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Borderline personality disorder (BPD) is characterized by interpersonal dysfunction.

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In BPD, the superior temporal sulcus is hyperactivated during social anticipation.

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In BPD, amygdala response to evaluative social feedback is also reduced.

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Amygdala suppression is induced by anterior cingulate rise during social anticipation.

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Atypical frontolimbic interactions may contribute to interpersonal dysfunction in BPD.

Background-

Borderline personality disorder (BPD) is characterized by maladaptive social functioning, and widespread negativity biases. The neural underpinnings of these impairments remain elusive. We thus tested whether BPD patients show atypical neural activity when processing social (compared to non-social) anticipation, feedback, and particularly, how they relate to each other.

Methods-

We acquired functional MRI data from 21 BPD women and 24 matched healthy controls (HCs) while they performed a task in which cues and feedbacks were either social (neutral faces for cues; happy or angry faces for positive and negative feedbacks, respectively) or non-social (dollar sign; winning or losing money for positive and negative feedbacks, respectively). This task allowed for the analysis of social anticipatory cues, performance-based feedback, and their interaction.

Results-

Compared to HCs, BPD patients expressed increased activation in the superior temporal sulcus during the processing of social cues, consistent with elevated salience associated with an upcoming social event. BPD patients also showed reduced activation in the amygdala while processing evaluative social feedback. Importantly, perigenual anterior cingulate cortex (pgACC) activity during the presentation of the social cue correlated with reduced amygdala activity during the presentation of the negative social feedback in the BPD patients.

Conclusions-

These neuroimaging results clarify how BPD patients express altered responses to different types of social stimuli (i.e. social anticipatory cues and evaluative feedback) and uncover an atypical relationship between frontolimbic regions (pgACC-amygdala) over the time span of a social interaction. These findings may help to explain why BPD patients suffer from pervasive difficulties adapting their behavior in the context of interpersonal relationships and should be considered while designing better-targeted interventions.

Clinical, personality, and neurodevelopmental phenotypes in borderline personality disorder: a family study

BACKGROUND

Borderline personality disorder (BPD) is characterized by a heterogeneous clinical phenotype that emerges from interactions among genetic, biological, neurodevelopmental, and psychosocial factors. In the present family study, we evaluated the familial aggregation of key clinical, personality, and neurodevelopmental phenotypes in probands with BPD (n = 103), first-degree biological relatives (n = 74; 43% without a history of psychiatric disorder), and non-psychiatric controls (n = 99).

METHODS

Participants were assessed on DSM-IV psychiatric diagnoses, symptom dimensions of emotion dysregulation and impulsivity, 'big five' personality traits, and neurodevelopmental characteristics, as part of a larger family study on neurocognitive, biological, and genetic markers in BPD.

RESULTS

The most common psychiatric diagnoses in probands and relatives were major depression, substance use disorders, post-traumatic stress disorder, anxiety disorders, and avoidant personality disorder. There was evidence of familial aggregation for specific dimensions of impulsivity and emotion dysregulation, and the big five traits neuroticism and conscientiousness. Both probands and relatives reported an elevated neurodevelopmental history of attentional and behavioral difficulties.

CONCLUSIONS

These results support the validity of negative affectivity- and impulse-spectrum phenotypes associated with BPD and its familial risk. Further research is needed to investigate the aggregation of neurocognitive, neural and genetic factors in families with BPD and their associations with core phenotypes underlying the disorder.

A review of psychopathy and Cluster B personality traits and their neural correlates in female offenders

Although men commit more crime and are incarcerated at higher rates than women, women represent the fastest growing segment of the justice system. Empirical work suggests that psychopathy and Cluster B disorders are implicated in antisocial behavior across gender, and that neurobiological correlates of personality may inform such behavior. This review utilizes a gendered perspective to discuss psychopathy and Cluster B disorders in relation to antisocial behavior and incorporates work on neural correlates of personality disorders. Co-morbidity across these conditions may be partly explained by similar frontal deficits, reflective of disinhibition. Affective processing abnormalities appear to be characterized by distinct deficits in limbic/paralimbic regions, reflecting differential etiological underpinnings and behavioral outcomes. This review underscores the utility in examining personality pathology together with neurobiological and environmental factors. Methodological issues and clinical implications are also discussed.

Differential Susceptibility to the Environment and Borderline Personality Disorder

Evolutionary models of psychopathology can shed light on gene-environment interactions. Differential susceptibility to the environment means that heritable traits can have positive or negative effects, depending on environmental context. Thus, traits that increase risk for mental disorders when the environment is negative can be adaptive when the environment is positive. This model can be applied to borderline personality disorder, with predictors such as emotional dysregulation and impulsivity seen as temperamental variations leading to negative effects in an unfavorable environment but to positive effects in a favorable environment. This model may also be useful in conceptualizing the mechanisms of effective therapy for borderline personality disorder.

A Recurrent Question: What Is Borderline?

The status of borderline personality disorder (BPD) as a diagnostic category is a matter of continuing controversy. In the United States, BPD is one of the most frequent diagnoses of psychiatric inpatients, and a similar tendency emerges in Europe. Nearly all theoretical aspects of BPD have been questioned, including its very position as a personality disorder. In this article, we trace the evolution of the borderline concept from the beginning of the 20th century to the current psychometric research. We argue that the status of BPD is fraught with conceptual difficulties, including an unrecognized semantic drift of major phenomenological terms (e.g., identity), a lack of general principles for the distinction of BPD and the major psychiatric syndromes (e.g., schizophrenia spectrum disorders), and insufficient definitions of key nosological concepts. These difficulties illustrate general problems in today's psychiatry that require consideration.

The NIMH Research Domain Criteria (RDoC) Initiative and Its Implications for Research on Personality Disorder

PURPOSE OF REVIEW

We discuss the implications of the Research Domain Criteria (RDoC) initiative for neuroscience research on personality disorder (PD). To organize our review, we construct a preliminary conceptual mapping of PD symptom criteria onto RDoC constructs. We then highlight recent neuroscience research, often built around concepts that correspond to RDoC elements, and discuss the findings in reference to the constructs we consider most pertinent to PD.

RECENT FINDINGS

PD symptoms were strongly conceptually tied to RDoC constructs within the Social Processes domain, implicating brain systems involved in interpersonal rejection, facial emotion perception, and self-referential processes. Negative and Positive Valence Systems were conceptually associated with many PD symptoms, with particular relevance ascribed to the latter's Reward Valuation construct, which could reflect a more widespread disruption of computational processes involved in estimating the probability and benefits of a future outcome. Within the Cognitive Systems domain, the Cognitive Control construct mainly related to PD symptoms associated with impulse control, suggesting a connection to neural circuits that underlie goal selection and behavioral control. Arousal and Regulatory Systems could only be conceptually mapped onto PD symptoms through the Arousal construct, with different symptoms reflecting either a higher or lower biological sensitivity to internal and external stimuli. The RDoC framework has promise to advance neuroscience research on PD. The Social Processes domain is especially relevant to PD, although constructs falling within the other RDoC domains could also yield important insights into the neurobiology of PD and its connections with other forms of psychopathology. Identifying RDoC constructs (e.g., habit formation) that subserve more fundamental processes relevant to personality functioning warrants further investigation.