Neural correlates of distraction in borderline personality disorder before and after dialectical behavior therapy

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.

Amygdala response predicts clinical symptom reduction in patients with borderline personality disorder: A pilot fMRI study

Borderline personality disorder (BPD) is a prevalent, devastating, and heterogeneous psychiatric disorder. Treatment success is highly variable within this patient group. A cognitive neuroscientific approach to BPD might contribute to precision psychiatry by identifying neurocognitive factors that predict who will benefit from a specific treatment. Here, we build on observations that BPD is accompanied by the enhanced impact of the aversive effect on behavior and abnormal neural signaling in the amygdala. We assessed whether BPD is accompanied by abnormal aversive regulation of instrumental behavior and associated neural signaling, in a manner that is predictive of symptom reduction after therapy. We tested a clinical sample of 15 female patients with BPD, awaiting dialectical behavior therapy (DBT), and 16 matched healthy controls using fMRI and an aversive Pavlovian-to-instrumental transfer (PIT) task that assesses how instrumental behaviors are influenced by aversive Pavlovian stimuli. Patients were assessed 1 year after the start of DBT to quantify changes in BPD symptom severity. At baseline, behavioral aversive PIT and associated neural signaling did not differ between groups. However, the BOLD signal in the amygdala measured during aversive PIT was associated with symptom reduction at 1-year follow-up: higher PIT-related aversive amygdala signaling before treatment was associated with reduced clinical improvement at follow-up. Thus, within the evaluated group of BPD patients, the BOLD signal in the amygdala before treatment was related to clinical symptom reduction 1 year after the start of treatment. The results suggest that less PIT-related responsiveness of the amygdala increases the chances of treatment success. We note that the relatively small sample size is a limitation of this study and that replication is warranted.

Emotion regulation strategies among individuals with borderline personality disorder relative to other groups: A review

Borderline personality disorder (BPD) is associated with difficulties in emotion regulation (ER) abilities. Investigations of ER strategies in BPD have been less robust. This systematic review identified 55 studies comparing ER strategy use between individuals diagnosed with BPD versus psychiatric and non-psychiatric comparison groups. Individuals with BPD reported more frequent maladaptive and less frequent adaptive ER strategy use than non-psychiatric controls. Results were less consistent relative to psychiatric comparison groups, though individuals with BPD reported greater self-criticism and avoidance. Groups responded comparably to instructed use of adaptive (but not maladaptive) ER strategies. This body of research would benefit from further examination of the roles of psychiatric comorbidity and problematic behaviours in the relationship between BPD and ER strategies.

Borderline personality disorder

Borderline personality disorder (BPD) is a mental disorder with a high burden on patients, family members, and health-care systems. The condition was previously regarded as untreatable, but progress in understanding and management has resulted in earlier diagnosis and better treatment outcomes. A coherent syndrome of BPD typically onsets during adolescence (after age 12 years). BPD is often preceded by or co-develops with symptoms of internalising disorders (depression and anxiety), externalising disorders (conduct problems, hyperactivity, and substance use), or both. BPD is associated with various poor outcomes, including low occupational and educational attainment, lack of long-term relationships, increased partner conflict, sexual risk-taking, low levels of social support, low life satisfaction, and increased service use. Psychotherapy is the main treatment for BPD; drug treatment is only indicated for comorbid conditions that require medication, or during a crisis if psychosocial interventions are insufficient. Awareness of BPD by non-specialists, as well as specialists, is key to appropriate early intervention.

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.

Functional MRI findings in personality disorders: A review

Personality disorders (PDs) have a prevalence of approximately 10% in the United States, translating to over 30 million people affected in just one country. The true prevalence of these disorders may be even higher, as the paucity of objective diagnostic criteria could be leading to underdiagnosis. Because little is known about the underlying neuropathologies of these disorders, patients are diagnosed using subjective criteria and treated nonspecifically. To better understand the neural aberrancies responsible for these patients' symptoms, a review of functional MRI literature was performed. The findings reveal that each PD is characterized by a unique set of activation changes corresponding to individual structures or specific neural networks. While unique patterns of neural activity are distinguishable within each PD, aberrations of the limbic/paralimbic structures and default mode network are noted across several of them. In addition to identifying valuable activation patterns, this review reveals a void in research pertaining to paranoid, schizoid, histrionic, narcissistic, and dependent PDs. By delineating patterns in PD neuropathology, we can more effectively direct future research efforts toward enhancing objective diagnostic techniques and developing targeted treatment modalities. Furthermore, understanding why patients are manifesting certain symptoms can advance clinical awareness and improve patient outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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.

[New insights into diagnostics and therapy of personality disorders-Changes in ICD-11]

Personality disorders (PD) occur frequently and show high remission rates in the long term, while psychosocial recovery remains unsuccessful in a substantial proportion of cases. In ICD-11 the traditional view that PDs have a high stability is abandoned. Instead, the minimum duration is 2 years. The diagnostic process differentiates between three degrees of severity (mild, moderate, severe) and five prominent personality trait domains. Optionally, a borderline qualifying factor can be additionally codified. There is sufficient empirical evidence only for the treatment of borderline PD (BPD). Disorder-specific psychotherapy, in particular dialectic behavioral therapy (DBT) and mentalization-based therapy (MBT) have proven to be effective. Therapy modules targeting functional impairments and prominent personality trait domains could close the existing gaps in the disorder-specific treatment of PD.

Mechanisms of change in brief treatments for borderline personality disorder: a protocol of a randomized controlled trial

BACKGROUND

Borderline personality disorder (BPD) is one of the most frequent, most debilitating and lethal mental conditions and is associated with a serious burden of disease. Treatment for patients with BPD involves structured psychotherapy, and may involve brief psychiatric treatment as first-line intervention. No controlled study has assessed the effectiveness of such brief intervention. Whereas most psychotherapy studies in patients with BPD focus on the effectiveness of the intervention, we still lack an understanding of how and why these effects are produced from a patient process perspective. It is therefore of utmost importance to study the treatment-underlying mechanisms of change. The present study plans to apply novel measurement methods for assessing change in two central psychobiological processes in BPD: emotion and socio-cognitive processing. The study uses theory-driven and ecologically valid experimental tasks, which take the patient's individual experience as the anchor, by integrating methodology from psychotherapy process and neurofunctional imagery research.

METHODS

The aim of this two-arm, randomized controlled study is to test the effects (i.e., symptom reduction) and the underlying mechanisms of change associated with a brief psychiatric treatment (10 sessions over 4 months), compared with treatment as usual. Participants (N = 80 patients with BPD) undergo assessments at four points (intake, 2 months, discharge, and 12-month follow up). In addition to symptom measures, individuals undergo a 2-step assessment for the potential mechanisms of change (i.e., emotion and socio-cognitive processing): (1) behavioral and (2) (for a sub-sample) neurofunctional. We hypothesize that change in the mechanisms explains the treatment effects.

DISCUSSION

This study uses an easy-to-implement treatment of BPD, and a sophisticated assessment procedure to demonstrate the critical role of psychobiological change in emotion and socio-cognitive processing in brief treatments. It will help increase the effectiveness of brief treatment for BPD and help diminish the societal burden of disease related to BPD, in these early stages of treatment. TRIAL REGISTRATION {2}: ClinicalTrials.gov: NCT03717818. Registered on 24 October 2018). Protocol version {3} number 2 from 9 February 2018.

Individualized treatment response prediction of dialectical behavior therapy for borderline personality disorder using multimodal magnetic resonance imaging

INTRODUCTION

Individualized treatment prediction is crucial for the development and selection of personalized psychiatric interventions. Here, we use random forest classification via pretreatment clinical and demographical (CD), functional, and structural magnetic resonance imaging (MRI) data from patients with borderline personality disorder (BPD) to predict individual treatment response.

METHODS

Before dialectical behavior therapy (DBT), 31 female patients underwent functional (three different emotion regulation tasks) and structural MRI. DBT response was predicted using CD and MRI data in previously identified anatomical regions, which have been reported to be multimodally affected in BPD.

RESULTS

Amygdala and parahippocampus activation during a cognitive reappraisal task (in contrasts displaying neural activation for emotional challenge and for regulation), along with severity measures of BPD psychopathology and gray matter volume of the amygdala, provided best predictive power with neuronal hyperractivities in nonresponders. All models, except one model using CD data solely, achieved significantly better accuracy (>70.25%) than a simple all-respond model, with sensitivity and specificity of >0.7 and >0.7, as well as positive and negative likelihood ratios of >2.74 and <0.36 each. Surprisingly, a model combining all data modalities only reached rank five of seven. Among the functional tasks, only the activation elicited by a cognitive reappraisal paradigm yielded sufficient predictive power to enter the final models.

CONCLUSION

This proof of principle study shows that it is possible to achieve good predictions of psychotherapy outcome to find the most valid predictors among numerous variables via using a random forest classification approach.

Borderline Personality Disorder in Patients With Medical Illness: A Review of Assessment, Prevalence, and Treatment Options

OBJECTIVE

Borderline personality disorder (BPD) occurs in 0.7% to 3.5% of the general population. Patients with BPD experience excessive comorbidity of psychiatric and somatic diseases and are known to be high users of health care services. Because of a range of challenges related to adverse health behaviors and their interpersonal style, patients with BPD are often regarded as "difficult" to interact with and treat optimally.

METHODS

This narrative review focuses on epidemiological studies on BPD and its comorbidity with a specific focus on somatic illness. Empirically validated treatments are summarized, and implementation of specific treatment models is discussed.

RESULTS

The prevalence of BPD among psychiatric inpatients (9%-14%) and outpatients (12%-18%) is high; medical service use is very frequent, annual societal costs vary between &OV0556;11,000 and &OV0556;28,000. BPD is associated with cardiovascular diseases and stroke, metabolic disease including diabetes and obesity, gastrointestinal disease, arthritis and chronic pain, venereal diseases, and HIV infection as well as sleep disorders. Psychotherapy is the treatment of choice for BPD. Several manualized treatments for BPD have been empirically validated, including dialectical behavior therapy, transference-focused psychotherapy, mentalization-based therapy, and schema-focused therapy.

CONCLUSIONS

Health care could be substantially improved if all medical specialties would be familiar with BPD, its pathology, medical and psychiatric comorbidities, complications, and treatment. In mental health care, several empirically validated treatments that are applicable in a wide range of clinical settings are available.

Nonacceptance of negative emotions in women with borderline personality disorder: association with neuroactivity of the dorsal striatum

BACKGROUND

Emotion dysfunction is a key symptom in patients with borderline personality disorder (BPD) and is considered a consequence of dysfunctional emotion regulation (e.g., reduced emotion acceptance). In the present functional MRI (fMRI) study, we investigated the neural correlates of habitual emotion acceptance in individuals with BPD.

METHODS

Female patients with BPD and female healthy controls passively viewed negative and neutral movie clips of faces during fMRI. We assessed emotion acceptance using the Emotion Acceptance Questionnaire (EAQ). To examine brain activation associated with habitual emotional acceptance of negative stimuli, the EAQ score was included as a regressor of interest in brain data analyses of activation intensity during negative compared with neutral movies.

RESULTS

We included 20 women with BPD and 20 heatlhy controls in our analysis. Compared with healthy controls, patients with BPD showed significantly more activation in frontostriatal brain regions (i.e., left superior frontal gyrus, right caudate) as well as in the left precuneus, left precentral gyrus, left posterior cingulate cortex and left hippocampus when confronted with negative (v. neutral) stimuli. Patients with BPD reported decreased emotion acceptance compared with healthy controls, and habitual emotion acceptance was inversely associated with activation of striatal areas (i.e., left putamen, left caudate) in patients with BPD.

LIMITATIONS

Causal conclusions are not possible. Comorbid diagnoses were not excluded, and only female participants were investigated. Stimuli were not rated immediately and may not be generalizable to all negative emotions. We cannot make any statements about other emotion-regulation strategies that may have been applied here.

CONCLUSION

Data indicate that striatal hyperactivation during the processing of negative stimuli in women with BPD is related to their decreased disposition to accept unpleasant emotional states. Thus, individuals with BPD may benefit from therapy approaches that focus on emotion acceptance in order to normalize emotional reactions.

[Borderline personality : Alterations to brain structure and function through psychotherapy]

BACKGROUND

There are now several scientifically evaluated psychotherapeutic methods for borderline personality disorder (BPD), all of which aim to improve the ability to regulate emotions. In recent years, there have been first studies on the neuronal correlates of the mechanisms of emotion regulation and of changes caused by psychotherapeutic interventions.

METHODS

This article reviews the data on functional and structural imaging studies that examine facets of disturbed emotion regulation before and after psychotherapy.

RESULTS

Although the overall database is still sparse, clinical improvement in psychotherapy appears to be associated with modulation of brain structure and function. Frontolimbic regulation circuits including the amygdala, insula, anterior cingulate cortex (ACC) and other prefrontal areas appear to be involved in these changes. An important finding is the reduction of initially increased amygdala activity after successful Dialectical Behavior Therapy (DBT).

CONCLUSION

The changes shown here most probably reflect an improvement in emotion regulation capacities in BPD and demonstrate the possibility of modulating disturbed emotion regulation processes. Since long-term follow-up data are still missing, the sustainability of the suggestive improvements still has to be proven in further studies.

Neurobiological and clinical effect of metacognitive interpersonal therapy vs structured clinical model: study protocol for a randomized controlled trial

BACKGROUND

Borderline Personality Disorder (BPD) is a complex and debilitating disorder, characterized by deficits in metacognition and emotion dysregulation. The "gold standard" treatment for this disorder is psychotherapy with pharmacotherapy as an adjunctive treatment to target state symptoms. The present randomized clinical trial aims to assess the clinical and neurobiological changes following Metacognitive Interpersonal Therapy (MIT) compared with Structured Clinical Management (SCM) derived from specific recommendations in APA (American Psychiatric Association) guidelines for BPD.

METHODS

The study design is a randomized parallel controlled clinical trial and will include 80 BPD outpatients, aged 18-45 enrolled at 2 recruitment centers. Primary outcome will be the clinical change in emotion regulation capacities assessed with the Difficulties in Emotion Regulation Scale (DERS). We will also investigated the effect of psychotherapy on metacognitive abilities and several clinical features such as BPD symptomatology, general psychopathology, depression, personal functioning, and trait dimensions (anger, impulsivity, alexithymia). We will evaluate changes in brain connectivity patterns and during the view of emotional pictures. A multidimensional assessment will be performed at the baseline, at 6, 12, 18 months. We will obtain structural and functional Magnetic Resonance Images (MRIs) in MIT-Treated BPD (N = 30) and SCM-treated BPD (N = 30) at baseline and after treatment, as well as in a group of 30 healthy and unrelated volunteers that will be scanned once for comparison.

DISCUSSION

The present study could contribute to elucidate the neurobiological mechanisms underlying psychotherapy efficacy. The inclusion of a multidisciplinary study protocol will allow to study BPD considering different features that can affect the treatment response and their reciprocal relationships.

TRIAL REGISTRATION

NCT02370316 . Registered 02/24/2015.

Neural Correlates of Affective Disturbances: A Comparative Meta-analysis of Negative Affect Processing in Borderline Personality Disorder, Major Depressive Disorder, and Posttraumatic Stress Disorder

BACKGROUND

Borderline personality disorder (BPD), major depressive disorder (MDD), and posttraumatic stress disorder (PTSD) are prominent examples of mental disorders with affective disturbances. Notably, all three disorders share a generally heightened negative affect, which is presumably the result of shared neural abnormalities in affective processing. In this meta-analysis, we aimed to identify transdiagnostic and disorder-specific abnormalities during the processing of negative compared with neutral stimuli.

METHODS

We synthesized neuroimaging findings of affect processing in BPD, MDD, and PTSD and calculated combined coordinate- and image-based meta-analyses. The analysis comprised 70 distinct study samples with a total of 31 unthresholded statistical parametric maps. Twenty-four studies had a focus on BPD (431 individuals with BPD, 436 healthy control subjects [HCs]), 32 studies on MDD (789 individuals with current MDD, 870 HCs), and 14 studies on PTSD (247 individuals with PTSD, 245 HCs).

RESULTS

Findings showed limbic hyperactivations in BPD and PTSD compared with limbic activation of HCs. In contrast, patients with MDD showed blunted amygdala activation in comparison with that of HCs. Additionally, the calculation of overlapping brain abnormalities in BPD, MDD, and PTSD highlighted transdiagnostic hyperactivation of the right median cingulate gyri and hypoactivation of the right middle frontal gyrus and the right middle occipital gyrus. Finally, disorder-specific comparisons also illustrate unique abnormalities for each mental disorder.

CONCLUSIONS

The present results support shared and disorder-specific neural abnormalities in patients with affective disturbances.

Treatment-induced brain plasticity in borderline personality disorder: review of functional MRI studies

Although neural substrates of symptoms expression in borderline personality disorder (BPD) have been studied extensively, neural mechanisms mediating post treatment amelioration of symptoms remain poorly characterized. Herein present review sheds a critical light on all here-to-date functional MRI findings of brain changes in BPD patients following a treatment with psychotherapy or drugs. Preliminary evidence points to downregulation of neuronal activity within the insula and amygdala, together with differential employment of prefrontal areas, mainly orbitofrontal cortex, anterior cingulate cortex and dorsolateral prefrontal cortex, as well as enhanced functional connectivity between limbic and prefrontal regions induced by dialectical behavioral therapy. Identifying neural circuits behind treatment processes may refine strategies to target specific symptoms, thereby resolving some of the controversies over BPD treatment.

Neurobiological Mechanisms Mediating Emotion Dysregulation as Targets of Change in Borderline Personality Disorder

Emotion dysregulation is a hallmark of borderline personality disorder (BPD). Most interventions for patients with BPD, therefore, aim at the improvement of emotion regulation. In the current paper, we provide an overview of studies investigating the effects of psychotherapeutic or pharmacological interventions on neurobiological correlates of various aspects of emotion regulation. In fact, studies suggest that the prefrontal-limbic circuit may play a major role in mediating effects of clinically efficacious psychotherapeutic treatments, i.e., they lead to clinical improvement via modulating the function and structure of the amygdala, the insula, and the dorsal anterior cingulate cortex, as well as prefrontal areas involved in the cognitive regulation of emotions, and enhancing the coupling of limbic and prefrontal areas. Oxytocin as a promising pharmacological approach to emotion dysregulation in BPD was shown to dampen amygdala activity in response to emotional stimuli. Understanding the brain mechanisms that mediate treatment effects will harness further development of targeted mechanism-based interventions for patients with BPD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Psychotherapy for Borderline Personality Disorder: Progress and Remaining Challenges

PURPOSE

The main purpose of this review was to critically evaluate the literature on psychotherapies for borderline personality disorder (BPD) published over the past 5 years to identify the progress with remaining challenges and to determine priority areas for future research.

METHOD

A systematic review of the literature over the last 5 years was undertaken.

RESULTS

The review yielded 184 relevant abstracts, and after applying inclusion criteria, 16 articles were fully reviewed based on the articles' implications for future research and/or clinical practice.

CONCLUSION

Our review indicated that patients with various severities benefited from psychotherapy; more intensive therapies were not significantly superior to less intensive therapies; enhancing emotion regulation processes and fostering more coherent self-identity were important mechanisms of change; therapies had been extended to patients with BPD and posttraumatic stress disorder; and more research was needed to be directed at functional outcomes.

Dissociation and Alterations in Brain Function and Structure: Implications for Borderline Personality Disorder

Dissociation involves disruptions of usually integrated functions of consciousness, perception, memory, identity, and affect (e.g., depersonalization, derealization, numbing, amnesia, and analgesia). While the precise neurobiological underpinnings of dissociation remain elusive, neuroimaging studies in disorders, characterized by high dissociation (e.g., depersonalization/derealization disorder (DDD), dissociative identity disorder (DID), dissociative subtype of posttraumatic stress disorder (D-PTSD)), have provided valuable insight into brain alterations possibly underlying dissociation. Neuroimaging studies in borderline personality disorder (BPD), investigating links between altered brain function/structure and dissociation, are still relatively rare. In this article, we provide an overview of neurobiological models of dissociation, primarily based on research in DDD, DID, and D-PTSD. Based on this background, we review recent neuroimaging studies on associations between dissociation and altered brain function and structure in BPD. These studies are discussed in the context of earlier findings regarding methodological differences and limitations and concerning possible implications for future research and the clinical setting.

Attention to emotional stimuli in borderline personality disorder - a review of the influence of dissociation, self-reference, and psychotherapeutic interventions

Interactions between attention and processing of emotional stimuli shed light on both sensitivity to emotional stimuli as well as emotion dysregulation. Both of the latter processes have been proposed as central characteristics of altered emotion processing in those with borderline personality disorder (BPD). This review first summarizes the conflicting behavioural, psychophysiological and neuroimaging evidence for the hypothesis that emotional dysregulation should be reflected by higher distractibility through emotional stimuli in those with BPD. Dissociation, self-reference, as well as symptom severity modulated by psychotherapeutic interventions are proposed to help clarify divergent findings. Data suggest an association of dissociation with impaired task continuation during the presentation of interfering emotional and neutral stimuli, as well as high recruitment of neuronal attention networks together with a blunted emotional response. Considering self-reference, evidence suggests that negative rather than positive information may be more self-relevant to those with BPD. This may be due to a negative self-concept and self-evaluation. Social or trauma-relevant information attracts more attention from individuals with BPD and thus suggests higher self-relevance. After psychotherapeutic interventions, initial evidence may indicate normalization of the way attention and emotional stimuli interact in BPD. When studying attention-emotion interactions in BPD, methodological heterogeneities regarding sample, task, and stimulus characteristics need to be considered. When doing so, dissociation, self-reference, and psychotherapeutic interventions offer promising targets for future studies on attention-emotion interactions in those with BPD. This could promote a deeper insight into the affected individuals' struggle with emotions.