Regional cortical thinning may be a biological marker for borderline personality disorder

Childhood adversity modulates structural brain changes in borderline personality but not in major depression disorder

Adverse childhood experiences (ACEs) negatively affect the function and structure of emotion brain circuits, increasing the risk of various psychiatric disorders. It is unclear if ACEs show disorder specificity with respect to their effects on brain structure. We aimed to investigate whether the structural brain effects of ACEs differ between patients with major depression (MDD) and borderline personality disorder (BPD). These disorders share many symptoms but likely have different etiologies. To achieve our goal, we obtained structural 3T-MRI images from 20 healthy controls (HC), 19 MDD patients, and 18 BPD patients, and measured cortical thickness and subcortical gray matter volumes. We utilized the Adverse Childhood Experiences (ACE) questionnaire to quantify self-reported exposure to childhood trauma. Our findings suggest that individuals with MDD exhibit a smaller cortical thickness when compared to those with BPD. However, ACEs showed a significantly affected relationship with cortical thickness in BPD but not in MDD. ACEs were found to be associated with thinning in cortical regions involved in emotional behavior in BPD, whereas HC showed an opposite association. Our results suggest a potential mechanism of ACE effects on psychopathology involving changes in brain structure. These findings highlight the importance of early detection and intervention strategies.

Altered cortical thickness and emotional dysregulation in adolescents with borderline personality disorder

Background: Emotional dysregulation is a core feature of borderline personality disorder (BPD). Previous studies have reported that abnormal grey matter volume is associated with the limbic-cortical circuit and default mode network (DMN) in patients with BPD. However, alterations of cortical thickness in adolescents with BPD have not been well evaluated.Objective: The aim of this study was to assess cortical thickness and its association with emotional dysregulation in adolescents with BPD.Method: This prospective study enrolled 52 adolescents with BPD and 39 age- and sex-matched healthy controls (HCs). Assessments included brain magnetic resonance imaging (MRI) acquisition with structural and resting-state functional MRI data, and clinical assessment for emotional dysregulation using the Difficulties in Emotion Regulation Scale (DERS). Cortical thickness and seed-based functional connectivity were analysed with FreeSurfer 7.2 software. Correlation analysis between cortical thickness and the scores from emotional assessment was performed with Spearman analysis.Results: Compared to HCs, there was altered cortical thickness in the DMN and limbic-cortical circuit in adolescents with BPD (Monte Carlo correction, all p < .05). These regions with altered cortical thickness were significantly associated with emotional dysregulation (all p < .05). There were also alterations of functional connectivity, i.e. with increased connectivity of the right prefrontal cortex with bilateral occipital lobes, or with the limbic system, and with decreased connectivity among the DMN regions (voxel p < .001, cluster p < .05, family-wise error corrected).Conclusions: Our results suggest that the altered cortical thickness and altered functional connectivity in the limbic-cortical circuit and DMN may be involved in emotional dysregulation in adolescents with BPD.

Childhood trauma and cortical thickness in healthy women, women with post-traumatic stress disorder, and women with borderline personality disorder

BACKGROUND

Structural brain changes have been associated with childhood trauma (CT) and several trauma-associated mental disorders. It is not known whether specific brain alterations are rather associated with CT as such or with disorders that are common sequelae of CT. In this study, we characterized cortical thickness in three distinct groups with CT: healthy women (HC/CT), women with posttraumatic stress disorder (PTSD/CT) and women with borderline personality disorder (BPD/CT). These three CT-exposed groups were compared with healthy controls not exposed to CT (HC).

METHODS

We recruited 129 women (n = 70 HC, n = 25 HC/CT, n = 14 PTSD/CT, and n = 20 BPD/CT) and acquired T1-weighted anatomical images. FreeSurfer was used for conducting whole-brain cortical thickness between-group comparisons, applying separate generalized linear models to compare cortical thickness of each CT-exposed group with HC.

RESULTS

The HC/CT group had lower cortical thickness in occipital lobe areas (right lingual gyrus, left lateral occipital lobe) than the HC group. The BPD/CT group showed a broader pattern of reduced cortical thickness compared to the HC group, including the bilateral superior frontal gyrus, and bilateral isthmus, the right posterior, and left caudal anterior of the cingulate cortex as well as the right lingual gyrus of the occipital lobe. We found no differences between PTSD/CT and HC.

CONCLUSIONS

Cortical thickness reduction in the right lingual gyrus of the occipital lobe seem to be related to CT but is also present in BPD patients even after adjusting for severity of CT. Possibly, reduced cortical thickness in the lingual gyrus presents a CT-related vulnerability factor for CT-related adult psychopathologies such as BPD. Reduced cortical thickness in the frontal and cingulate cortex may represent unique neuroanatomical markers of BPD possibly related to difficulties in emotion regulation.

Alteration of surface morphology and core features in adolescents with borderline personality disorder

BACKGROUND

Accurate early diagnosis of adolescent borderline personality disorder (BPD) is critical for prompt treatment. The aim of this study was to assess the alteration of brain surface morphology and to evaluate its relationship with core features in adolescent BPD.

METHODS

A total of 52 adolescents with BPD aged 12-17 years and 39 age- and sex-matched healthy controls (HCs) were prospectively enrolled into the study. Brain magnetic resonance imaging (MRI) was obtained with both 3D-T1 weighted structural sequence and resting-state functional data. The structural data was analyzed for surface morphology parameters including the local gyrification index (LGI), mean curvature and surface area. The functional MRI data was analyzed for seed-based functional connectivity (FC). Correlative analysis of surface morphology and core features of adolescent BPD was performed.

RESULTS

Adolescents with BPD showed the following altered surface morphology in the limbic-cortical circuit when compared to the HCs: (1) reduced LGI in the left fusiform and right superior temporal gyrus; (2) reduced mean curvature in the left precentral gyrus and right rostral anterior cingulate cortex, and increased mean curvature in the bilateral pericalcarine; and (3) reduced surface area in the left paracentral gyrus, left pars triangularis, right insula and right lateral orbitofrontal gyrus (P < 0.05, FWE correction). In addition, these brain regions with altered surface morphology were significantly correlated with several core features including the mood instability, self-identity problems, and non-suicidal self-injury behavior in adolescents with BPD (P < 0.05). Furthermore, there was enhanced functional connectivity among these altered brain regions within the limbic-cortical circuit (voxel P < 0.001, cluster P < 0.05, FWE corrected).

CONCLUSIONS

Adolescents with BPD had significant alterations of brain surface morphology in the limbic-cortical circuit, which was correlated with core BPD features. These results implicated the surface morphology parameters and FC alterations may potentially serve as neuroimaging biomarkers for adolescents with BPD.

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

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

Looking at the bigger picture: Cortical volume, thickness and surface area characteristics in borderline personality disorder with and without posttraumatic stress disorder

Borderline personality disorder (BPD) is a severe psychiatric disorder accompanied by multiple comorbidities. Neuroimaging studies have identified structural abnormalities in BPD with most findings pointing to gray matter volume reductions in the fronto-limbic network, although results remain inconsistent. Similar alterations were found in posttraumatic stress disorder (PTSD), a common comorbidity of BPD. Only a small number of studies have investigated structural differences in BPD patients regarding comorbid PTSD specifically and studies conducting additional surface analyses are scarce. We investigated structural differences in women with BPD with and without PTSD and non-patient controls. Automated voxel-based and region-based volumetric analyses were applied. Additionally, four surface-based measures were analyzed: cortical thickness, gyrification index, fractal dimension, and sulcus depth. Analyses did not identify cortical volume alterations in the fronto-limbic network. Instead, hypergyrification was detected in the right superior parietal cortex in BPD patients compared to non-patient controls. No distinction was revealed between BPD patients with and without PTSD. These findings underline the importance of a holistic investigation examining volumetric and surface measures as these might enhance the understanding of structural alterations in BPD.

The role of impairments in self-other distinction in borderline personality disorder: A narrative review of recent evidence

Impairments in maintaining a differentiated sense of "self" and "other" are thought to be a central feature of borderline personality disorder (BPD). However, studies directly focusing on self-other distinction (SOD) in BPD are scarce, and these findings have not yet been integrated with novel insights into the neural mechanism involved in SOD. Here, we present a narrative review of recent behavioral and neuroimaging findings focusing on impairments in SOD in BPD. Behavioral findings of SOD at the embodied level provide preliminary evidence for impairments in multisensory integration in BPD. Furthermore, both behavioral and neuroscientific data converge to suggest that SOD impairments in BPD reflect an inability to shift between self and other representations according to task demands. Research also suggests that disruptions in infant-caregiver synchrony may play a role in the development of these impairments. Based on these findings, we present a new, integrative model linking impairments in SOD to reduced neural and behavioral synchrony in BPD. The implications of these findings for future research and clinical interventions are outlined.

Meta-Analysis of white matter diffusion tensor imaging alterations in borderline personality disorder

Borderline personality disorder (BorPD) is characterized by instability and mood dysregulation, unstable relationships and distorted self-image. Identification of underlying anatomical and physiological changes is crucial to refine current treatments and develop new ones. In this perspective, previous magnetic resonance imaging studies have highlighted alterations associated with BorPD phenotype. In particular, diffusion-weighted imaging/Diffusion tensor imaging (DWI/DTI) has identified many white matter structural alterations in individuals with this diagnosis. Although in its infancy, limiting this line of investigation is a lack of direction at the field level. Hence, the present paper aims to conduct a meta-analysis of DWI/DTI findings in individuals with a diagnosis of BorPD, testing the hypothesis that there are specific white matter alterations associated with BorPD. To this end, we performed a meta-analysis of the existing literature of DWI/DTI in BorPD representing a total of 123 individuals with BorPD and 117 Controls. Our results indicated that individuals with BorPD show regions of reduced fractional anisotropy in the corpus callosum and fornix. These results survived all jack-knife reshuffles and showed no publication bias. This suggests that alterations in these structures may contribute to psychopathology. Further, the present results lend support to extant psychological and biological models of BorPD.

Alexithymia Is Associated with Altered Cortical Thickness Networks in the General Population

BACKGROUND

Alexithymia is a personality trait characterized by difficulties in identifying and describing emotions and associated with various psychiatric disorders. Neuroimaging studies found evidence for morphological and functional brain alterations in alexithymic subjects. However, the neurobiological mechanisms underlying alexithymia remain incompletely understood.

METHODS

We study the association of alexithymia with cortical correlation networks in a large community-dwelling sample of the Study of Health in Pomerania. Our analysis includes data of n = 2,199 individuals (49.4% females, age = 52.1 ± 13.6 years) which were divided into a low and high alexithymic group by a median split of the Toronto Alexithymia Scale. Cortical correlation networks were constructed based on the mean thicknesses of 68 regions, and differences in centralities were investigated.

RESULTS

We found a significantly increased centrality of the right paracentral lobule in the high alexithymia network after correction for multiple testing. Several other regions with motoric and sensory functions showed altered centrality on a nominally significant level.

CONCLUSIONS

Finding increased centrality of the paracentral lobule, a brain area with sensory as well as motoric features and involvement in bowel and bladder voiding, may contribute to explain the association of alexithymia with functional somatic disorders and chronic pain syndromes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

Relatively small sample size, especially for neuroimaging.

CONCLUSIONS

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

Dysfunction of Empathy and Related Processes in Borderline Personality Disorder: A Systematic Review

After participating in this activity, learners should be better able to:• Assess differences between adult patients with the diagnosis of borderline personality disorder (BPD) and healthy control subjects in terms of empathy and related processes• Evaluate the effects of empathy or related processes as factors contributing to abnormal social functioning in BPD ABSTRACT: We reviewed 45 original research studies, published between 2000 and 2019, to assess differences between adult patients with the diagnosis of borderline personality disorder (BPD) and healthy control subjects in terms of empathy and related processes (i.e., theory of mind, mentalizing, social cognition, and emotional intelligence). Thirty-six studies reported deficits of empathy or related processes in patients with BPD. Enhanced emotional empathy in BPD was also reported in eight studies, all of which revealed that patients had increased scores of personal distress on the Interpersonal Reactivity Index self-report questionnaire. Six studies did not find significant differences between patients with BPD and healthy control subjects in terms of empathy or related processes. No study reported enhanced cognitive empathy, social cognition, or emotional intelligence in patients with BPD. We postulate that deficits of empathy or related processes contribute to preempting the formation of stable interpersonal relationships, whereas enhanced emotional empathy might lead to personal (and interpersonal) distress, further contributing to abnormal social functioning in BPD.

Cortical thickness patterns as state biomarker of anorexia nervosa

OBJECTIVE

Only few studies have investigated cortical thickness in anorexia nervosa (AN), and it is unclear whether patterns of altered cortical thickness can be identified as biomarkers for AN.

METHOD

Cortical thickness was measured in 19 adult women with restricting-type AN, 24 individuals recovered from restricting-type AN (REC-AN) and 24 healthy controls. Those individuals with current or recovered from AN had previously shown altered regional cortical volumes across orbitofrontal cortex and insula. A linear relevance vector machine-learning algorithm estimated patterns of regional thickness across 24 subdivisions of those regions.

RESULTS

Region-based analysis showed higher cortical thickness in AN and REC-AN, compared to controls, in the right medial orbital (olfactory) sulcus, and greater cortical thickness for short insular gyri in REC-AN versus controls bilaterally. The machine-learning algorithm identified a pattern of relatively higher right orbital, right insular and left middle frontal cortical thickness, but lower left orbital, right middle and inferior frontal, and bilateral superior frontal cortical thickness specific to AN versus controls (74% specificity and 74% sensitivity, χ² p < .004); predicted probabilities differed significantly between AN and controls (p < .023). No pattern significantly distinguished the REC-AN group from controls.

CONCLUSIONS

Higher cortical thickness in medial orbitofrontal cortex and insula probably contributes to higher gray matter volume in AN in those regions. The machine-learning algorithm identified a mixed pattern of mostly higher orbital and insular, but relatively lower superior frontal cortical thickness in individuals with current AN. These novel results suggest that regional cortical thickness patterns could be state markers for AN.

Hemispheric asymmetry of the frontolimbic cortex in young adults with borderline personality disorder

OBJECTIVE

Although the frontolimbic cortex has been implicated in borderline personality disorder (BPD), information about possible asymmetries in this region in patients with BPD is limited. This study aimed to examine whether frontolimbic cortex asymmetries differ between patients with BPD and healthy individuals.

METHODS

The brains of 30 young adult patients with BPD and 32 healthy control subjects were scanned with magnetic resonance imaging (MRI). The participants completed self-report scales assessing impulsivity, affect intensity and other psychological variables. Gray matter volume, surface area, and cortical thickness in regions of interest (ROIs), namely anterior insula (AI) and anterior cingulate cortex (ACC) were determined and the data were probed for hemisphere-group interactions.

RESULTS

Relative to controls, patients with BPD had reduced cortical thickness in left ACC and less surface area and gray matter volume in left AI. Significant group-hemisphere interactions were observed for gray matter volume and surface area of AI and for cortical thickness of ACC. Post hoc analysis showed that the BPD patients had greater frontolimbic cortex asymmetry than healthy controls; furthermore, greater asymmetry of AI&ACC correlated with a higher score in attention subscale of Barratt Impulsiveness Scale.

CONCLUSION

Patients with BPD have greater frontolimbic asymmetry than healthy individuals.

When personality is the problem: Managing patients with difficult personalities on the acute care unit

Personality disorders are pervasive patterns of maladaptive behaviors, thoughts, and emotions that often go unrecognized and can wreak havoc in the patient's interpersonal life. These inflexible patterns of managing the world can be disruptive when an individual is admitted to the hospital, causing distress for both the patient who lacks the skills to deal with the expectations of the hospital environment and the treatment team who can feel ill equipped to manage such behavior. Having a personality disorder has implications for an individual's healthcare outcomes; those with a personality disorder have a life expectancy nearly 2 decades shorter than the general population for a multitude of reasons, among them trouble interacting with the healthcare system. Although a diagnosis of a specific personality disorder may be difficult to make on an acute care unit, identification of dysfunctional personality structures can provide opportunity for better management of an individual patient's medical and psychological needs. This review focuses on the identification of these individuals in the acute care setting and provides an overview of evidence-based behavioral and pharmacological interventions. Journal of Hospital Medicine 2015;11:873-878. © 2015 Society of Hospital Medicine.

Abnormalities in cortical gray matter density in borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is a chronic condition with a strong impact on patients' affective, cognitive and social functioning. Neuroimaging techniques offer invaluable tools to understand the biological substrate of the disease. We aimed to investigate gray matter alterations over the whole cortex in a group of Borderline Personality Disorder (BPD) patients compared to healthy controls (HC).

METHODS

Magnetic resonance-based cortical pattern matching was used to assess cortical gray matter density (GMD) in 26 BPD patients and in their age- and sex-matched HC (age: 38 ± 11; females: 16, 61%).

RESULTS

BPD patients showed widespread lower cortical GMD compared to HC (4% difference) with peaks of lower density located in the dorsal frontal cortex, in the orbitofrontal cortex, the anterior and posterior cingulate, the right parietal lobe, the temporal lobe (medial temporal cortex and fusiform gyrus) and in the visual cortex (P<0.005). Our BPD subjects displayed a symmetric distribution of anomalies in the dorsal aspect of the cortical mantle, but a wider involvement of the left hemisphere in the mesial aspect in terms of lower density. A few restricted regions of higher density were detected in the right hemisphere. All regions remained significant after correction for multiple comparisons via permutation testing.

CONCLUSIONS

BPD patients feature specific morphology of the cerebral structures involved in cognitive and emotional processing and social cognition/mentalization, consistent with clinical and functional data.

Complex PTSD, affect dysregulation, and borderline personality disorder

Complex PTSD (cPTSD) was formulated to include, in addition to the core PTSD symptoms, dysregulation in three psychobiological areas: (1) emotion processing, (2) self-organization (including bodily integrity), and (3) relational security. The overlap of diagnostic criteria for cPTSD and borderline personality disorder (BPD) raises questions about the scientific integrity and clinical utility of the cPTSD construct/diagnosis, as well as opportunities to achieve an increasingly nuanced understanding of the role of psychological trauma in BPD. We review clinical and scientific findings regarding comorbidity, clinical phenomenology and neurobiology of BPD, PTSD, and cPTSD, and the role of traumatic victimization (in general and specific to primary caregivers), dissociation, and affect dysregulation. Findings suggest that BPD may involve heterogeneity related to psychological trauma that includes, but extends beyond, comorbidity with PTSD and potentially involves childhood victimization-related dissociation and affect dysregulation consistent with cPTSD. Although BPD and cPTSD overlap substantially, it is unwarranted to conceptualize cPTSD either as a replacement for BPD, or simply as a sub-type of BPD. We conclude with implications for clinical practice and scientific research based on a better differentiated view of cPTSD, BPD and PTSD.