Evidence of abnormal amygdala functioning in borderline personality disorder: a functional MRI study

The role of functional neuroimaging in exploring the overlap between borderline personality disorder and bipolar disorder

In light of the recent discussions of possible diagnostic overlap between borderline personality disorder and bipolar disorder, we explored the neuroimaging literature to determine if findings from this literature might illuminate the issue of overlap between the two diagnoses. We looked at studies of executive functions and emotion-related functions. Although similar brain areas have been explored in each population and several findings are suggestive of overlap, as well as differences between the two disorders, conclusions are limited because of the lack of studies that employed the exact same paradigm in the two patient groups. The authors suggest methods for conducting future neuroimaging research that may better clarify some of these issues of possible diagnostic overlap.

Processing of autobiographical memory retrieval cues in borderline personality disorder

BACKGROUND

Affective dysregulation in borderline personality disorder (BPD) in response to both external stimuli and memories has been shown to be associated with functional alterations of limbic and prefrontal brain areas. This study aimed to examine neuronal networks involved in autobiographical memory retrieval using standardized stimuli that gain autobiographical significance by illustrating marked solitary and social situations of human life.

METHODS

Using event-related functional Magnetic Resonance Imaging (fMRI), we examined the processing of pictures from the Thematic Apperception Test (TAT) in 14 BPD patients and 14 controls.

RESULTS

In both groups, TAT stimuli activated brain areas known to be involved in autobiographical memory retrieval. BPD subjects lacked differential amygdala, orbitofrontal and cingulate activations for TAT versus neutral stimuli. In the TAT condition, compared to controls, BPD subjects displayed increased BOLD responses in the bilateral orbitofrontal and insular regions, in the left anterior cingulate and medial prefrontal cortex, as well as in the parietal and parahippocampal areas, consistent with a more aversive and arousing experience assessed by self-reports.

CONCLUSIONS

Increased BOLD responses during TAT processing in BPD subjects were in line with previously reported changes in anterior cingulate and orbitofrontal cortices, which are known to be involved in memory retrieval. However, BPD subjects displayed hyperactivation in these areas for both TAT and neutral stimuli. The deficit of selective activation of areas involved in autobiographical memory retrieval suggests a general tendency towards a self-referential mode of information processing in BPD, or a failure to switch between emotionally salient and neutral stimuli.

Psychotherapy for patients with borderline personality disorder: focusing on the mechanisms of change

A major development in the field of psychotherapy research is the growing recognition of the need for evidence on the mechanisms of change in psychotherapy. The empirical evidence that psychotherapy has a positive and significant effect must be amplified with data on the mechanisms of action in the various psychotherapies. This special issue is devoted to the articulation of putative mechanisms of change in the psychotherapy of patients with borderline personality disorder by leading researchers in this field.

Amygdala volume and depressive symptoms in patients with borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is characterized by a high prevalence of comorbid psychiatric disorders, including major depression (MD). The aim of this study was to examine whether a co-occurrence of MD is associated with structural changes in the amygdala of BPD patients.

METHODS

Twenty-five right-handed, female patients with BPD and 25 matched healthy control subjects were examined. Diagnoses of BPD and MD were made according to DSM IV. Depressive symptomatology was determined with the Hamilton Depression Scale (HAMD). Magnetic resonance imaging scans were performed with 1.5 T Magnetom Vision (Siemens, Erlangen, Germany). The software program "BRAINS" was applied for brain volumetry and segmentation. The amygdala was delineated as "region of interest."

RESULTS

Comparison of amygdala volumes between the whole group of BPD patients and control subjects revealed no significant difference. Amygdala volumes in both hemispheres were significantly larger in BPD patients with MD compared with those without MD. There was a significant correlation in BPD patients between left amygdala volume and depressive symptoms as measured by HAMD.

CONCLUSIONS

Correlation of amygdala volume with depression in BPD patients might indicate a causal relationship. Future studies should clarify whether amygdala enlargement is a risk factor for MD in BPD patients or a consequence of the affective disorder.

Neuroimaging in borderline personality disorder

Neuroimaging has become one of the most important methods in the investigation of the neurobiological underpinnings of borderline personality disorder. Structural and functional imaging studies have revealed dysfunction in different brain regions which seem to contribute to borderline symptomatology. This review presents relevant studies using different methodologies: volumetry of limbic and prefrontal regions, investigations of brain metabolism under resting conditions, studies of serotonergic neurotransmission, and challenge studies using emotional, stressful, and sensory stimuli. Dysfunction in a frontolimbic network is suggested to mediate much, if not all of the borderline symptomatology.

The psychodynamics of borderline personality disorder: a view from developmental psychopathology

This article provides a contemporary view of the psychodynamics of borderline personality disorder (BPD) from a developmental psychopathology perspective. We first briefly describe the evolution of the borderline construct in psychoanalysis and psychiatry. Then we provide clinically and empirically informed model of domains of personality function and dysfunction that provides a roadmap for thinking about personality pathology from a developmental psychopathology standpoint and examine the nature and phenomenology of BPD in terms of these domains of functioning. Next, we describe prominent dynamic theories of etiology of BPD and examine these in relation to the available research. Finally, we describe psychodynamic conceptions of treatment and the way BPD phenomena manifest in treatment, followed again by consideration of relevant research, particularly on transference-countertransference constellations empirically identified in the treatment of patients with BPD.

Developmental psychopathology and neurobiology of aggression

The aim of this paper is to clarify how neural mechanisms at the molecular level, specifically the serotonergic (5-HT) system and the hypothalamic-pituitary-adrenal axis system (HPA) in conjunction with early life stress may contribute to the emergence of aggression, self-directed and otherwise, in borderline personality disorder (BPD). Chronic dysregulation of these biological systems, which function to regulate stress and emotion, may potentiate the development of impulsive aggression in borderline personality conditions. Our central premise in this paper is that brain development, stress regulation, and early pathonomic experience are interactive and cumulative in their mutual influence on the development of impulsive aggression in BPD. We review the parameters of impulsive aggression in BPD, followed by a discussion of the neurobiological and neuroendocrine correlates of impulsive aggression with and without BPD. We then focus on the developmental continuities in BPD with attention to brain maturation of 5-HT and HPA axis function during the life span and the influence of early adverse experiences on these systems. Finally, we comment on the data of the relative stability of aggression in BPD, adolescence as a developmental stage of potential vulnerability, and the course of aggressive behavior during the life span.

Emotion dysregulation and the development of borderline personality disorder

We review the role of emotion regulation in borderline personality disorder (BPD). We briefly discuss the historical development of BPD as a disorder where emotional regulation plays a key role. We review the concept of emotion regulation in general and explore both one-factor and two-factor models of emotion regulation. We discuss cognitive and attentional aspects of emotion regulation, and explore these regulatory controls as operating as both voluntary as well as automatic processes. We then turn to other neurophysiological models of emotion regulation in general and examine how those models, both neurophysiologically and neuroanatomically, are expressed in individuals with BPD. We examine how neuroimaging, both anatomical and functional, reveals the roles that various neuroanatomical structures play in the regulation of emotion in BPD. We conclude by creating a neurodevelopmental model that describes how a complex matrix involving the interplay of constitutional/biological predispositions with environmental stressors as well as with parental effectiveness in response to the child's emotion expression can impact key aspects of adult cognitive, affective, interpersonal, and behavioral functioning that culminate in a diagnosis of BPD.

Neurocognitive impairment as a moderator in the development of borderline personality disorder

Borderline personality disorder (BPD) is characterized by a pervasive instability of interpersonal relationships, affects, self-image, marked impulsivity, dissociation, and paranoia. The cognitive dimension of the disorder has received relatively little attention and is poorly understood. This paper proposes that neurocognitive impairment is a key moderator in the development of BPD and elaborates a possible pathway for the expression of the cognitive domain. Neurocognitive impairment is hypothesized to moderate the relationship between caretaking and insecure disorganized attachment and pathological dissociation in the formation of the disorder contributing to impaired metacognition and a range of cognitive difficulties. The empirical evidence from studies of cognitive processes, brain function, attachment, and dissociation that support this theory are reviewed and discussed. Areas for future research that might verify or refute this theory are suggested.

Imaging emotional brain functions: conceptual and methodological issues

This article reviews the psychophysiological and brain imaging literature on emotional brain function from a methodological point of view. The difficulties in defining, operationalising and measuring emotional activation and, in particular, aversive learning will be considered. Emotion is a response of the organism during an episode of major significance and involves physiological activation, motivational, perceptual, evaluative and learning processes, motor expression, action tendencies and monitoring/subjective feelings. Despite the advances in assessing the physiological correlates of emotional perception and learning processes, a critical appraisal shows that functional neuroimaging approaches encounter methodological difficulties regarding measurement precision (e.g., response scaling and reproducibility) and validity (e.g., response specificity, generalisation to other paradigms, subjects or settings). Since emotional processes are not only the result of localised but also of widely distributed activation, a more representative model of assessment is needed that systematically relates the hierarchy of high- and low-level emotion constructs with the corresponding patterns of activity and functional connectivity of the brain.

Coalescence of psychiatry, neurology, and neuropsychology: from theory to practice

In a climate of renewed interest in the synergy between neurology and psychiatry, practitioners are increasingly recognizing the importance of exchange and collaboration between these two disciplines. However, there are few working models of interdisciplinary teams that freely share expertise in real time, while providing clinical and academic training to future physicians who specialize in the central nervous system. Over the past 11 years, the McLean Hospital Neuropsychiatry and Behavioral Neurology service has provided proof-of-principle for such collaboration, demonstrating that a team comprising psychiatrists, neurologists, and neuropsychologists can function effectively as a unit while maintaining the autonomy of these three disciplines and also synthesizing their combined knowledge. In addition to delivering enhanced patient care and promoting medical research, this clinical service has provided enriched cross-specialty training for fellows, residents, and medical students. The practical functioning of the team is described, and case vignettes are presented to illustrate the team's collaborative synergism in practice.

Re-evaluating the distinction between Axis I and Axis II disorders: the case of borderline personality disorder

The division between Axis I clinical syndromes and Axis II personality disorders is a long-standing distinction based primarily on three guiding principles: phenomenology, cause, and course. Clinical syndromes were generally thought to be characterized by transient symptoms with biological causes and an unstable course; personality disorders were supposed by many to be characterized by long-standing personality traits, whose roots were primarily psychological, and a stable and unremitting course. Borderline personality disorder (BPD), however, is a condition characterized by distinct clinical symptoms, varied causes, and a relatively unstable course. Past theorizing about the distinction between Axis I and Axis II disorders is presented in light of recent empirical evidence refuting the rationalization for the separation of personality disorders and clinical syndromes using BPD as a means for comparison.

Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders

OBJECTIVES

The Diagnostic and Statistical Manual of Mental Disorders guidelines provide only a partial solution to the nosology and treatment of bipolar disorder in that disorders with common symptoms and biological correlates may be categorized separately because of superficial differences related to behavior, life history, and temperament. The relationship is explored between extremely rapid switching forms of bipolar disorder, in which manic and depressive symptoms are either mixed or switch rapidly, and forms of borderline personality disorder in which affective lability is a prominent symptom.

METHODS

A MedLine search was conducted of articles that focused on rapid cycling in bipolar disorder, emphasizing recent publications (2001-2004).

RESULTS

Studies examined here suggest a number of points of phenomenological and biological overlap between the affective lability criterion of borderline personality disorder and the extremely rapid cycling bipolar disorders. We propose a model for the development of 'borderline' behaviors on the basis of unstable mood states that sheds light on how the psychological and somatic interventions may be aimed at 'breaking the cycle' of borderline personality disorder development. A review of pharmacologic studies suggests that anticonvulsants may have similar stabilizing effects in both borderline personality disorder and rapid cycling bipolar disorder.

CONCLUSIONS

The same mechanism may drive both the rapid mood switching in some forms of bipolar disorder and the affective instability of borderline personality disorder and may even be rooted in the same genetic etiology. While continued clinical investigation of the use of anticonvulsants in borderline personality disorder is needed, anticonvulsants may be useful in the treatment of this condition, combined with appropriate psychotherapy.

Psychological, autonomic, and serotonergic correlates of parasuicide among adolescent girls

Although parasuicidal behavior in adolescence is poorly understood, evidence suggests that it may be a developmental precursor of borderline personality disorder (BPD). Current theories of both parasuicide and BPD suggest that emotion dysregulation is the primary precipitant of self-injury, which serves to dampen overwhelmingly negative affect. To date, however, no studies have assessed endophenotypic markers of emotional responding among parasuicidal adolescents. In the present study, we compare parasuicidal adolescent girls (n=23) with age-matched controls (n=23) on both psychological and physiological measures of emotion regulation and psychopathology. Adolescents, parents, and teachers completed questionnaires assessing internalizing and externalizing psychopathology, substance use, trait affectivity, and histories of parasuicide. Psychophysiological measures including electrodermal responding (EDR), respiratory sinus arrhythmia, and cardiac pre-ejection period (PEP) were collected at baseline, during negative mood induction, and during recovery. Compared with controls, parasuicidal adolescents exhibited reduced respiratory sinus arrhythmia (RSA) at baseline, greater RSA reactivity during negative mood induction, and attenuated peripheral serotonin levels. No between-group differences on measures of PEP or EDR were found. These results lend further support to theories of emotion dysregulation and impulsivity in parasuicidal teenage girls.

Defining the neurocircuitry of borderline personality disorder: Functional neuroimaging approaches

Functional neuroimaging recently has been used to localize brain dysfunction in borderline personality disorder (BPD). Initial studies have examined baseline activity or emotional reactivity, and our group has investigated what we consider to be a crucial interaction between negative emotion and behavioral (dys)control. This research is beginning to identify abnormal frontolimbic circuitry likely underlying core clinical features of this condition. We review the evidence for dysfunction in specific frontolimbic regions, leading to a mechanistic model of symptom formation in BPD. In addition, we offer an integration of these neuroimaging findings with developmental perspectives on the emergence of borderline psychopathology, focusing on the ways in which early psychosocial experience may interact with developing brain systems. We also consider possible mechanisms of psychotherapeutic change at the neural systems level in BPD. Finally, we propose that future neuroimaging studies of BPD should integrate multiple levels of observation (structural, functional, neurochemical, genetic, and clinical) in a model-driven fashion to further understand the dynamic relationship between biological and psychological factors in the development and treatment of this difficult condition.

Developmental precipitants of borderline personality disorder

Traditional theories regarding the etiology of borderline personality disorder have focused on poor attachment figures and/or traumatic experience. The present review posits an additional pathogenic course for this disorder. Specifically, the proposed mechanism involves a basic disruption of the neural hardware that supports the formation and maintenance of unconscious emotional memory, hardware essential for the formation of early attachments. It is further theorized that this early disruption has ongoing effects on both behavioral and concomitant neural development. Within this model, adolescence is described as a period of intense change that serves as the tipping point for the onset of borderline personality disorder.

Endophenotypes in the personality disorders

The identification of endophenotypes in the personality disorders may provide a basis for the identification of underlying genotypes that influence the traits and dimensions of the personality disorders, as well as susceptibility to major psychiatric illnesses. Clinical dimensions of personality disorders that lend themselves to the study of corresponding endophenotypes include affective instability impulsiwity aggression, emotional information processing, cognitive disorganization, social deficits, and psychosis. For example, the propensity to aggression can be evaluated by psychometric measures, interview, laboratory paradigms, neurochemical imaging, and pharmacological studies. These suggest that aggression is a measurable trait that may be related to reduced serotonergic activity. Hyperresponsiveness of amygdala and other limbic structures may be related to affective instability, while structural and functional brain alterations underlie the cognitive disorganization in psychoticlike symptoms of schizotypal personality disorder. Thus, an endophenotypic approach not only provides clues to underlying candidate genes contributing to these behavioral dimensions, but may also point the way to a better understanding of pathophysiological mechanisms.

Reduced anterior and posterior cingulate gray matter in borderline personality disorder

BACKGROUND

Structural abnormalities in prefrontal and cingulate gyrus regions-important in affective processing, impulse control and cognition may contribute to the psychopathology of borderline personality disorder (BPD). Previous MRI studies examining volume have reported that compared with healthy controls, BPD patients have decreases in right anterior cingulate, no differences in dorsolateral prefrontal cortex, and mixed findings for prefrontal cortex. We extended this investigation by examining gray and white matter volume of frontal and cingulate gyrus Brodmann areas (BAs) in a large group of patients and healthy controls.

METHODS

MRI scans were acquired in 50 BPD patients (n = 13 with comorbid diagnosis of BPD and Schizotypal Personality Disorder (SPD) and n = 37 without SPD) and 50 healthy controls, and gray/white matter volume in cingulate gyrus and frontal lobe BAs were assessed. Normal BPD and BPD subgroup comparisons were conducted.

RESULTS

Compared with controls, BPD patients showed reduced gray matter volume in BA 24 and 31 of the cingulate. BPD patients without comorbid SPD had isolated gray matter volume loss in BA 24, but were spared for BA 31 in contrast to BPD patients with SPD. There were no group differences in whole cingulate or frontal lobe volume.

CONCLUSIONS

The finding of more pervasive cingulate shrinkage in the patients with BPD and SPD comorbidity resembles recent observations with the same methods in patients with schizophrenia. The pattern of reduced anterior and posterior cingulate gray matter volume in BPD patients, particularly those comorbid for SPD is consistent with the affective and attentional deficits observed in these personality disorders.

Adolescent alcohol use disorders predict adult borderline personality

BACKGROUND

This study investigated adolescent alcohol use disorders (AUDs) and other characteristics as predictors of adult borderline personality disorder (BPD) symptoms.

METHODS

Adolescents with AUDs (n = 355) were recruited from clinical treatment sources and adolescents without AUDs (n = 169) were recruited from the community. During an adolescent assessment (age 16+/-1.3), childhood physical and/or sexual abuse history, AUDs and associated psychiatric disorders were measured via semi-structured interviews. Symptoms of BPD were measured in a young adult follow-up assessment (age 22+/-2.4). Latent class analysis was utilized to classify individuals into four categories based upon BPD symptom profiles.

RESULTS

Multinomial regression models indicated that adolescent AUDs and other psychiatric disorders mediated the relationship between child physical and/or sexual abuse and adult BPD latent class.

CONCLUSIONS

Results were consistent with a developmental conceptualization of BPD, with AUDs and other adolescent psychopathology antecedents representing developmentally relevant forms of dysregulation, and in their more severe forms culminating in borderline symptomatology.

Facial expression of emotions in borderline personality disorder and depression

Borderline personality disorder (BPD) is characterized by marked problems in interpersonal relationships and emotion regulation. The assumption of emotional hyper-reactivity in BPD is tested regarding the facial expression of emotions, an aspect highly relevant for communication processes and a central feature of emotion regulation. Facial expressions of emotions are examined in a group of 30 female inpatients with BPD, 27 women with major depression and 30 non-patient female controls. Participants were videotaped while watching two short movie sequences, inducing either positive or negative emotions. Frequency of emotional facial expressions and intensity of happiness expressions were examined, using the Emotional Facial Action Coding System (EMFACS-7, Friesen & Ekman, EMFACS-7: Emotional Facial Action Coding System, Version 7. Unpublished manual, 1984). Group differences were analyzed for the negative and the positive mood-induction procedure separately. Results indicate that BPD patients reacted similar to depressed patients with reduced facial expressiveness to both films. The highest emotional facial activity to both films and most intense happiness expressions were displayed by the non-clinical control group. Current findings contradict the assumption of a general hyper-reactivity to emotional stimuli in patients with BPD.

Reduced glucose metabolism in temporo-parietal cortices of women with borderline personality disorder

Individuals with borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) often experience dissociative symptoms. Evidence is increasing that stress-related hyperglutamatergic states may contribute to dissociative symptoms and neurodegeneration in temporo-parietal cortical areas. Seventeen young women with BPD who had been exposed to severe childhood physical/sexual abuse and presented with pronounced dissociative symptoms underwent (18)fluoro-2-deoxyglucose positron emission tomography (FDG-PET). Nine healthy, matched volunteers served as comparison subjects. Borderline subjects displayed reduced FDG uptake (as analyzed by SPM) in the right temporal pole/anterior fusiform gyrus and in the left precuneus and posterior cingulate cortex. Impaired memory performance among borderline subjects was significantly correlated with metabolic activity in ventromedial and lateral temporal cortices. Our results demonstrate regional hypometabolism in temporal and medial parietal cortical regions known to be involved in episodic memory consolidation and retrieval. Currently, the precuneus/posterior cingulate cortex is modeled as part of a network of tonically active brain regions that continuously gather information about the world around and within us. Decreased resting metabolic rate of these regions may reflect dissociative symptoms and possibly also identity disturbances and interpersonal difficulties of individuals with BPD.

Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with borderline personality disorder and healthy controls

Patients with borderline personality disorder (BPD) were compared with a healthy control group with regard to traumatic life events during childhood. The patients (n=66) and controls (n=109) were investigated using a comprehensive retrospective interview with 203 questions about childhood traumatic life events, parental attitudes, family history of psychiatric disorders and birth risk factors. The frequency of reports of traumatic childhood experiences was significantly higher in patients than in controls, including sexual abuse, violence, separation from parents, childhood illness, and other factors. On a 0- to 10-point "severe trauma scale," patients had significantly more severe traumatic events (mean score=3.86, SD=1.77) than control subjects (0.61, SD=0.93). Only four (6.1%) of the BPD patients, but 67 (61.5%) of the controls did not report any severe traumatic events at all. Compared with controls, patients described the attitude of their parents as significantly more unfavorable in all aspects. Patients reported significantly higher rates of psychiatric disorders in their families in general, especially anxiety disorders, depression, and suicidality. Among birth risk factors, premature birth was reported more often in BPD subjects. In a logistic regression model of all possible etiological factors examined, the following factors showed a significant influence: familial neurotic spectrum disorders, childhood sexual abuse, separation from parents and unfavorable parental rearing styles. The present data support the hypothesis that the etiology of BPD is multifactorial and that familial psychiatric disorders and sexual abuse are contributing factors.

Borderline personality disorder features in adolescent girls: P300 evidence of altered brain maturation

OBJECTIVE

To examine brain maturation in adolescent girls with borderline personality disorder (BPD) features using the P300 event-related potential.

METHODS

One hundred twenty-three girls, aged 14-19 yrs, were assigned to one of 4 groups formed by the crossing of BPD features (vs. > or =5 BPD criteria) and median age (vs. >16.5 yrs). P300 responses were measured while subjects performed a complex visual oddball task.

RESULTS

ANCOVAs of P300 amplitude-adjusting for variability associated with comorbid conduct disorder and depression symptoms--revealed a significant interaction. Among subjects without BPD features, aging was associated with the normal reduction in visual P300 amplitude. Among subjects with BPD features, there were no age-related changes. Additional analyses, which tested the effects of BPD features across the full age range, supported these findings.

CONCLUSIONS

The present findings suggest abnormal brain maturation among adolescent girls exhibiting features of BPD.

SIGNIFICANCE

These results support a hypothesis of altered brain maturation in adolescents exhibiting BPD features at an early age. It is suggested that measures of brain maturation obtained during adolescence may improve our ability to predict BPD and comorbid disorders in adulthood.

Neuroimaging and personality disorders

Within the past several years, neuroimaging research on personality disorders has begun to develop. Personality disorders can be thought of as trait-like dysfunctional patterns in cognitive, affective, impulse control, and interpersonal domains. These domains of dysfunction have been linked to specific neural circuits. Developments in brain imaging techniques have allowed researchers to examine the neural integrity of these circuits in personality-disordered individuals. This article reviews the neuroimaging literature on borderline personality disorder, antisocial personality disorder (including psychopathy) and schizotypal personality disorder. Functional and structural studies provide support for dysfunction in fronto-limbic circuits in borderline and antisocial personality disorder, whereas temporal lobe and basal striatal-thalamic compromise is evident in schizotypal personality disorder.

Reduced size and abnormal asymmetry of parietal cortex in women with borderline personality disorder

BACKGROUND

Evidence is accumulating that suggests borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) are related to small hippocampal size. Psychotic symptoms are frequent in both disorders. Psychotic spectrum disorders are known to be related to abnormalities of temporoparietal cortices.

METHODS

Using structural magnetic resonance imaging (3D-MRI), parietal cortex and hippocampal volumes were assessed in 30 young women with BPD who had been exposed to severe childhood sexual and physical abuse and in 25 healthy control subjects.

RESULTS

Compared with control subjects, BPD subjects had significantly smaller right parietal cortex (-11%) and hippocampal (-17%) volumes. The parietal cortex of borderline subjects showed a significantly stronger leftward asymmetry when compared with control subjects. Stronger psychotic symptoms and schizoid personality traits in borderline subjects were significantly related to reduced leftward asymmetry. Stronger trauma-related clinical symptoms and neuropsychologic deficits were significantly related to smaller hippocampal size.

CONCLUSIONS

Our results are consistent with previous findings of small hippocampal size in BPD and PTSD. Reduced right parietal cortex size in individuals with BPD may reflect a neurodevelopmental deficit of the right hemisphere.

Affective dysregulation and dissociative experience in female patients with borderline personality disorder: a startle response study

Affective dysregulation and dissociation are currently discussed as core features of borderline personality disorder (BPD). Affective dysregulation is hypothesized to be correlated with increased amygdala functioning and dissociation is linked to inhibited processing on the amygdala and dampened autonomic output, according to the corticolimbic disconnection model of dissociation from Sierra and Berrios [Biological Psychiatry 44 (1998) 898]. We assessed startle response, which is mainly mediated by the amygdala, to investigate the relationship between affective dysregulation and dissociation. We hypothesized that patients with BPD would reveal enhanced responses to startling tones, but that these would be lessened by the presence of state dissociative experiences. 21 unmedicated female patients with BPD and 21 healthy female controls listened to 15 startling tones (95-dB, 500-ms, 1000-Hz) while heart rate, skin conductance and orbicularis oculi electromyogram responses were measured. Covariance analysis showed that the BPD group had a significantly higher startle response in the electromyogram as compared to controls. Furthermore, present-state dissociative experiences significantly influenced the startle response. Patients with low dissociative experiences revealed enhanced startle responses whereas patients with high dissociative experiences showed reduced responses. Our data support affective dysregulation in BPD as well as the corticolimbic disconnection model of dissociation, at least for EMG. Furthermore, it highlights the importance of assessing present-state dissociation in basic research as well as psychotherapy.

Executive neurocognitive functioning and neurobehavioral systems indicators in borderline personality disorder: a preliminary study

It is argued that borderline personality disorder (BPD) represents the interaction of underlying neurobehavioral systems that are reflected principally in the phenotypic constructs of positive emotion, negative emotion, and nonaffective constraint (Depue & Lenzenweger, 2001). This preliminary and exploratory study sought to examine predictions made from the Depue-Lenzenweger model with respect to controlled (effortful) information processing in BPD. It was hypothesized that (a) BPD subjects may display deficits on tasks that require controlled information processing (sustained attention, spatial working memory, and executive functioning), (b) they may reveal elevated negative emotion as well as decreased positive emotion and nonaffective constraint, and (c) nonaffective constraint should be substantially inversely associated with accurate performance on controlled information processing tasks. The results of this study, which examined 24 BPD diagnosed individuals and 68 normal adults, found support for each of these predictions in relation to performance on the Wisconsin Card Sorting Test. The implications of these results for further experimental psychopathology investigations of BPD as well as further refinement of theoretical models of the disorder are discussed.

Borderline personality disorder

Borderline personality disorder is characterised by a pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image. Clinical signs of the disorder include emotional dysregulation, impulsive aggression, repeated self-injury, and chronic suicidal tendencies, which make these patients frequent users of mental-health resources. Causal factors are only partly known, but genetic factors and adverse events during childhood, such as physical and sexual abuse, contribute to the development of the disorder. Dialectical behaviour therapy and psychodynamic partial hospital programmes are effective treatments for out-of-control patients, and drug therapy can reduce depression, anxiety, and impulsive aggression. More research is needed for the understanding and management of this disabling clinical condition. Current strategies are focusing on the neurobiological underpinnings of the disorder and the development and dissemination of better and more cost-effective treatments to clinicians.

The roles of orbital frontal cortex in the modulation of antisocial behavior

This article considers potential roles of orbital frontal cortex in the modulation of antisocial behavior. Two forms of aggression are distinguished: reactive aggression elicited in response to frustration/threat and goal directed, instrumental aggression. It is suggested that orbital frontal cortex is directly involved in the modulation of reactive aggression. It is argued that orbital frontal cortex does not "inhibit" reactive aggression but rather may both increase or decrease its probability as a function of social cues present in the environment. Early dysfunction in this function of orbital frontal cortex may be linked to the development of Borderline Personality Disorder. Instrumental aggression is linked to a fundamental failure in moral socialization. However, the available data suggest that the amygdala, but not orbital frontal cortex, is required for functions such as aversive conditioning and passive avoidance learning that are necessary for moral socialization. Psychopathic individuals who present with significant instrumental aggression, are impaired in aversive conditioning and passive avoidance learning and show evidence of amygdala dysfunction. Orbital frontal cortex and the amygdala are involved in response reversal where instrumental responses must be reversed following contingency change. Impairments in response reversal are also seen in psychopathic individuals. However, it remains unclear whether impairment in response reversal per se is associated with antisocial behavior.

Dopamine dysfunction in borderline personality disorder: a hypothesis

Research on the biological basis of borderline personality disorder (BPD) has focused primarily on the serotonin model of impulsive aggression. However, there is evidence that dopamine (DA) dysfunction may also be associated with BPD. Pertinent research and review articles, identified by Medline searches of relevant topics, books, references from bibliographies, and conference proceedings from 1975 to 2003, were reviewed. Evidence of DA dysfunction in BPD derives from the efficacy of traditional and atypical antipsychotic agents in BPD, and from provocative challenges with amphetamine and methylphenidate of subjects with the disorder. In addition, human and animal studies indicate that DA activity plays an important role in emotion information processing, impulse control, and cognition. The results of this review suggest that DA dysfunction is associated with three dimensions of BPD, that is, emotional dysregulation, impulsivity, and cognitive-perceptual impairment. The main limitation of this hypothesis is that the evidence reviewed is circumstantial. There is no study that directly demonstrates DA dysfunction in BPD. In addition, the therapeutic effects of antipsychotic agents observed in BPD may be mediated by non-DA mechanisms of action. If the stated hypothesis is correct, DA dysfunction in BPD may result from genetic, developmental, or environmental factors directly affecting specific DA pathways. Alternatively, DA dysfunction in BPD may be a compensatory response to alterations in the primary neural systems that control emotion, impulse control, and cognition, and that are mediated by the brain's main neurotransmitters, glutamate, and GABA, or in one or more other neuromodulatory pathways such as serotonin, acetylcholine, and norepinephrine.

Posttraumatic stress disorder and fMRI activation patterns of traumatic memory in patients with borderline personality disorder

BACKGROUND

Early traumatization and additional posttraumatic stress disorder are frequent in patients with borderline personality disorder (BPD). The purpose of this study was to investigate neural correlates of traumatic memory in BPD with and without posttraumatic stress disorder (PTSD) using functional magnetic resonance imaging (fMRI).

METHODS

We studied 12 traumatized female patients BPD, 6 of them with and 6 without PTSD. According to an autobiographical interview key words (cues) were defined for traumatic and for negative but nontraumatic episodes. In a block-designed fMRI task patients recalled these episodes. Contrasts between trauma condition and nontrauma condition were analyzed.

RESULTS

Analyses for all subjects revealed activation of orbitofrontal cortex areas in both hemispheres, anterior temporal lobes, and occipital areas. In the subgroup without PTSD, activation of orbitofrontal cortex on both sides and Broca's area predominated. In the subgroup with additional PTSD, we observed right more than left activation of anterior temporal lobes, mesiotemporal areas, amygdala, posterior cingulate gyrus, occipital areas, and cerebellum.

CONCLUSIONS

Dependent on absence or presence of additional PTSD different neural networks seem to be involved in the traumatic memory of patients with BPD.

New developments in the neurobiology of borderline personality disorder

Within the past several years, research on the clinical phenomena and neurobiology of borderline personality disorder has increased substantially. Borderline personality disorder is currently best thought of in terms of dimensions rather than as a categorical disorder. This article reviews the most recent findings on two of the core dimensions--affective dysregulation and impulsivity. Most of the neuropsychologic, physiologic, endocrinologic, and neuroimaging data support the theory that a dual brain pathology, affecting prefrontal and limbic circuits, may underlie this hyperarousal-dyscontrol syndrome.

Neurobiological substrates of antisocial and borderline personality disorder: preliminary results of a functional fMRI study

BACKGROUND

Neuropsychological and imaging studies of patients with antisocial (ASPD) and borderline personality disorder (BPD) are suggestive of frontal lobe dysfunction in these individuals. In normal subjects functional brain imaging has been used to investigate the neuroanatomy of impulse control. There are no such imaging studies in personality-disordered populations.

AIM

This study aimed to investigate which neuronal networks are involved in response inhibition in Cluster B personality disorders and whether these are different from healthy subjects.

HYPOTHESIS

We hypothesized that the personality-disordered sample would have attenuated orbitofrontal cortex responses during performance of a Go/NoGo task compared with healthy controls.

METHOD

Eight inpatients with a DSM-IV diagnosis of borderline or antisocial personality disorder and eight healthy controls were scanned using fMRI while performing a Go/NoGo task. Impulsivity was assessed using the Barratt Impulsivity Scale (BIS) and the Impulsiveness-Venturesomeness-Empathy (IVE) inventory.

RESULTS

In the control group the main focus of activation during response inhibition was in the prefrontal cortex, specifically the right dorsolateral and the left orbitofrontal cortex. Active regions in the patient group showed a more bilateral and extended pattern of activation across the medial, superior and inferior frontal gyri extending to the anterior cingulate.

CONCLUSIONS

fMRI is a useful tool to detect brain activation during response inhibition. ASPD and BPD patients activate different neural networks to successfully inhibit pre-potent responses.

Amygdala hyperreactivity in borderline personality disorder: implications for emotional dysregulation

BACKGROUND

Disturbed interpersonal relations and emotional dysregulation are fundamental aspects of borderline personality disorder (BPD). The amygdala plays important roles in modulating vigilance and generating negative emotional states and is often abnormally reactive in disorders of mood and emotion. The aim of this study was to assess amygdala reactivity in BPD patients relative to normal control subjects. We hypothesized that amygdala hyperreactivity contributes to hypervigilance, emotional dysregulation, and disturbed interpersonal relations in BPD.

METHODS

Using functional magnetic resonance imaging, we examined neural responses to 20-sec blocks of neutral, happy, sad, and fearful facial expression (or a fixation point) in 15 BPD and 15 normal control subjects. The DSM IV-diagnosed BPD patients and the normal control subjects were assessed by a clinical research team in a medical school psychiatry department.

RESULTS

Borderline patients showed significantly greater left amygdala activation to the facial expressions of emotion (vs. a fixation point) compared with normal control subjects. Post-scan debriefing revealed that some borderline patients had difficulty disambiguating neutral faces or found them threatening.

CONCLUSIONS

Pictures of human emotional expressions elicit robust differences in amygdala activation levels in borderline patients, compared with normal control subjects, and can be used as probes to study the neuropathophysiologic basis of borderline personality disorder.

The role of childhood trauma in differences in affective instability in those with personality disorders

BACKGROUND

This study examined the relationship of self-reported histories of childhood trauma to measures of affective instability in a sample of unmedicated outpatients with various personality disorders (n=174).

METHODS

Childhood trauma was measured by the Childhood Trauma Questionnaire. Affective instability comprises at least two dimensions: affective lability, assessed using the Affective Lability Scale, and affective intensity, assessed using the Affective Intensity Measure.

RESULTS

A history of emotional abuse was the only trauma variable that significantly correlated with the affect measures in the total sample (r=.21-.30). More fine-grained analyses revealed that the relationship of emotional abuse and affective instability measures varied as a function of both gender and personality disorder type. In subjects with borderline personality disorder, the correlation for emotional abuse was greatly attenuated for both Affective Lability Scale (r=.10) and Affective Intensity Measure (r=.15) total scores.

CONCLUSION

This suggests that nontrauma-related factors may be more predominant in affective dyscontrol in individuals with borderline personality disorder.

A voxel-based morphometric MRI study in female patients with borderline personality disorder

Subtle prefrontal and limbic structural abnormalities have been reported in borderline personality disorder (BPD). In order to further validate the previously reported findings and to more precisely describe the nature of the structural change we performed a voxel-based morphometric (VBM) study in patients with BPD. Twenty female patients with BPD and 21 female healthy controls were investigated. High-resolution 3-D datasets were acquired and analyzed following an optimized protocol of VBM in the framework of statistical parametric mapping (SPM99). Gray matter volume loss was found in the left amygdala. No other differences in gray or white matter volume or density were found anywhere else in the brain. Our findings support the hypothesis that temporolimbic abnormalities play a role in the pathophysiology of BPD. Prefrontal structural alterations in BPD were not observed in this study.

Frontolimbic brain abnormalities in patients with borderline personality disorder: a volumetric magnetic resonance imaging study

BACKGROUND

Dual frontolimbic brain pathology has been suggested as a possible correlate of impulsivity and aggressive behavior. One previous study reported volume loss of the hippocampus and the amygdala in patients with borderline personality disorder. We measured limbic and prefrontal brain volumes to test the hypothesis that frontolimbic brain pathology might be associated with borderline personality disorder.

METHODS

Eight unmedicated female patients with borderline personality disorder and eight matched healthy controls were studied. The volumes of the hippocampus, amygdala, and orbitofrontal, dorsolateral prefrontal, and anterior cingulate cortex were measured in the patients using magnetic resonance imaging volumetry and compared to those obtained in the controls.

RESULTS

We found a significant reduction of hippocampal and amygdala volumes in borderline personality disorder. There was a significant 24% reduction of the left orbitofrontal and a 26% reduction of the right anterior cingulate cortex in borderline personality disorder. Only left orbitofrontal volumes correlated significantly with amygdala volumes.

CONCLUSIONS

While volume loss of a single brain structure like the hippocampus is quite an unspecific finding in neuropsychiatry, the patterns of volume loss of the amygdala, hippocampus, and left orbitofrontal and right anterior cingulate cortex might differentiate borderline personality disorder from other neuropsychiatric conditions.

Abnormalities in emotion processing within cortical and subcortical regions in criminal psychopaths: evidence from a functional magnetic resonance imaging study using pictures with emotional content

BACKGROUND

Neurobiology of psychopathy is important for our understanding of current neuropsychiatric questions. Despite a growing interest in biological research in psychopathy, its neural underpinning remains obscure.

METHODS

We used functional magnetic resonance imaging to study the influence of affective contents on brain activation in psychopaths. Series containing positive and negative pictures from the International Affective Picture System were shown to six male psychopaths and six male control subjects while 100 whole-brain echo-planar-imaging measurements were acquired. Differences in brain activation were evaluated using BrainVoyager software 4.6.

RESULTS

In psychopaths, increased activation through negative contents was found right-sided in prefrontal regions and amygdala. Activation was reduced right-sided in the subgenual cingulate and the temporal gyrus, and left-sided in the dorsal cingulate and the parahippocampal gyrus. Increased activation through positive contents was found left-sided in the orbitofrontal regions. Activation was reduced in right medial frontal and medial temporal regions.

CONCLUSIONS

These findings underline the hypotheses that psychopathy is neurobiologically reflected by dysregulation and disturbed functional connectivity of emotion-related brain regions. These findings may be interpreted within a framework including prefrontal regions that provide top-down control to and regulate bottom-up signals from limbic areas. Because of the small sample size, the results of this study have to be regarded as preliminary.

Emotional processing in personality disorder

In the field of personality disorders, borderline and antisocial types are associated with emotional dysfunctioning. In borderline personality disorder (BPD), the hypothesis of emotional hyperresponsiveness can be supported by several experimental studies that suggest highly intensive and slowly subsiding emotions to primed and non-primed stimuli, as well as by data showing biased information, which processes in the context of emotions. In addition, the first neuroimaging data suggest that limbic hypersensitivity is a neurofunctional correlate of emotional vulnerability in BPD. In antisocial psychopathic personality disorder, data confirm the theory of emotional detachment, subsuming fearlessness, and, beyond that, emotional indifference to appetitive stimuli. Because of a fundamental dysfunction in the amygdala, psychopathic individuals appear to use alternative cognitive operations of processing affective material to compensate for the absence of appropriate limbic input, which normally provides prompt information about the affective characteristics of stimuli.

The role of the parietal lobe in borderline personality disorder

Many patients with a diagnosis of borderline personality disorder describe multi-modal hallucinations. A likely cortical origin for multi-modal hallucinations is the inferior parietal lobule. Neuropsychological testing of borderline personality disorder reveals deficits of visuospatial capacity; a function which is also localised to the inferior parietal lobule. It is hypothesised that this brain area is likely to be dysfunctional in those patients with borderline personality disorder who have multi-modal hallucinations. A deficit in the inferior parietal lobe could plausibly explain a number of other clinical features; the gender dimorphism of this disorder, the lack of expressive gesture and the specific response to clozapine. More speculatively; the increased concern over this disorder over the past 40 years could result from the normal population showing an increase in functional ability in the parietal lobe, leaving patients with parietal deficits relatively more disabled.

The human amygdala and the emotional evaluation of sensory stimuli

A wealth of animal data implicates the amygdala in aspects of emotional processing. In recent years, functional neuroimaging and neuropsychological studies have begun to refine our understanding of the functions of the amygdala in humans. This literature offers insights into the types of stimuli that engage the amygdala and the functional consequences that result from this engagement. Specific conclusions and hypotheses include: (1) the amygdala activates during exposure to aversive stimuli from multiple sensory modalities; (2) the amygdala responds to positively valenced stimuli, but these responses are less consistent than those induced by aversive stimuli; (3) amygdala responses are modulated by the arousal level, hedonic strength or current motivational value of stimuli; (4) amygdala responses are subject to rapid habituation; (5) the temporal characteristics of amygdala responses vary across stimulus categories and subject populations; (6) emotionally valenced stimuli need not reach conscious awareness to engage amygdala processing; (7) conscious hedonic appraisals do not require amygdala activation; (8) activation of the amygdala is associated with modulation of motor readiness, autonomic functions, and cognitive processes including attention and memory; (9) amygdala activations do not conform to traditional models of the lateralization of emotion; and (10) the extent and laterality of amygdala activations are related to factors including psychiatric status, gender and personality. The strengths and weakness of these hypotheses and conclusions are discussed with reference to the animal literature.

Quantitative frontal and temporal structural MRI studies in personality-disordered offenders and control subjects

High rates of temporal and frontal lobe dysfunction have been reported in neuropsychological and EEG studies of incarcerated personality-disordered (PD) offenders, but there have been few quantitative structural magnetic resonance imaging (MRI) studies. We investigated whether impulsive-aggressive male PD patients showed evidence of reduced brain volumes in frontal and temporal brain regions on MRI compared with healthy control subjects. All subjects were screened for axis I pathology and brain abnormalities. Quantitative measures of frontal and temporal lobe volume were computed on MR images of the brain in 19 control subjects and 18 patients who did not show any evidence of brain pathology on diagnostic MRI scans. Temporal lobe volumes were 20% smaller in PD patients than control subjects, but the predicted reductions in frontal lobe volume did not occur, despite evidence of impairments in executive function. There was no evidence of differences in asymmetry of brain structures. The study further implicates temporal lobes in the pathogenesis of severe personality disorder, but does not support the notion that PDs characterised by impulsive-aggressive traits have abnormalities in brain symmetry similar to those reported in mentally ill populations. Higher-resolution MRI studies are needed to localise the abnormalities and to determine their nature.