Temporal glucose metabolism in borderline personality disorder

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

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

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

Borderline personality disorder (BPD) is a severe mental disorder with a multifactorial etiology. The development and maintenance of BPD is sustained by diverse neurobiological factors that contribute to the disorder's complex clinical phenotype. These factors may be identified using a range of techniques to probe alterations in brain systems that underlie BPD. We systematically searched the scientific literature for empirical studies on the neurobiology of BPD, identifying 146 articles in three broad research areas: neuroendocrinology and biological specimens; structural neuroimaging; and functional neuroimaging. We consolidate the results of these studies and provide an integrative model that attempts to incorporate the heterogeneous findings. The model specifies interactions among endogenous stress hormones, neurometabolism, and brain structures and circuits involved in emotion and cognition. The role of the amygdala in BPD is expanded to consider its functions in coordinating the brain's dynamic evaluation of the relevance of emotional stimuli in the context of an individual's goals and motivations. Future directions for neurobiological research on BPD are discussed, including implications for the Research Domain Criteria framework, accelerating genetics research by incorporating endophenotypes and gene × environment interactions, and exploring novel applications of neuroscience findings to treatment research.

Orbitofrontal cortex and impulsivity in borderline personality disorder: an MRI study of baseline brain perfusion

Behavioral and neuroimaging studies in patients with borderline personality disorder (BPD) have associated orbitofrontal cortex (OFC) dysfunction with distinct symptom clusters such as impulsivity. It is unclear, however, whether abnormal patterns of OFC activity are also present during resting-state conditions and whether OFC dysfunction is specifically associated with impulsivity in BPD. This study tested the hypothesis that BPD patients would exhibit changes of OFC baseline perfusion and explored the relationship between regional cerebral blood flow and distinct BPD symptom clusters, such as impulsivity, dissociation tension and depressive symptoms. Using continuous arterial spin labeling magnetic resonance imaging at 3 Tesla, we investigated 16 women with BPD according to DSM-IV criteria and 16 healthy female control participants during resting-state conditions. Between-group comparisons were conducted using an analysis of variance (p < 0.05 cluster corrected). Compared to controls, BPD patients exhibited decreased blood flow in the medial OFC, whereas increased blood flow was found in the left and right lateral OFC. Correlation analyses revealed a positive relationship between medial and lateral orbitofrontal blood flow and impulsivity scores, whereas measures of dissociation tension and depression did not exhibit a significant correlation with OFC perfusion. These data suggest that dysfunction of medial and lateral regions of the OFC could specifically mediate symptoms of impulsivity in BPD.

Aberrant connectivity of resting-state networks in borderline personality disorder

BACKGROUND

Several functional neuroimaging studies have reported regionally abnormal activation of the frontal cortex in individuals with borderline personality disorder (BPD) during cognitive and affective task performance. However, little is known about neural function in individuals with BPD during the resting state. Using functional magnetic resonance imaging (fMRI), this study investigated the functional connectivity of prefrontal and limbic networks in patients with BPD.

METHODS

Between January 2009 and March 2010, we investigated patients with BPD according to DSM-IV criteria and healthy controls by means of resting-state fMRI. The data were analyzed using a spatial group independent component analysis, and random effects t tests were used to compare spatial components between groups (p < 0.005, uncorrected).

RESULTS

There were 17 women with BPD and 17 female healthy controls enrolled in this study. Within a network comprising cortical midline regions ("default mode network"), patients with BPD showed an increase in functional connectivity in the left frontopolar cortex (FPC) and the left insula, whereas decreased connectivity was found in the left cuneus. Within a network comprising predominantly right lateral prefrontal and bilateral parietal regions, patients with BPD showed decreased connectivity of the left inferior parietal lobule and the right middle temporal cortex compared with healthy controls. Two networks comprising lateral prefrontal and cingulate regions did not exhibit significant between-group differences. We found correlations between functional connectivity of the FPC and measures of impulsivity as well as between connectivity of the insula/cuneus and dissociation tension.

LIMITATIONS

Co-occurrent axis I disorders and medication use in this sample of patients with BPD have to be considered as potential limitations.

CONCLUSION

These data suggest that abnormal functional connectivity of temporally coherent resting-state networks may underlie certain symptom clusters in patients with BPD.

Positron emission tomography of regional brain metabolic responses to a serotonergic challenge in major depressive disorder with and without borderline personality disorder

Previous neuroimaging studies of major depression have not controlled for the presence of personality disorders characterized by impulsive aggressive behavior, such as borderline personality disorder (BPD). Using positron emission tomography (PET), we studied regional glucose uptake in response to fenfluramine (FEN) in depressed subjects with BPD (n=11) and depressed patients without Cluster B Axis II disorders (n=8). Subjects were scanned while medication-free after a single blind placebo administration and after FEN on a second day. Brain responses were measured by PET imaging of [18F]fluorodeoxyglucose (FDG) and serial prolactin levels. Scans were compared at a voxel level using statistical parametric mapping. Correlations of changes in relative regional cerebral uptake (rCMRglu) with clinical measures were assessed. Depressed borderline patients had greater relative activity in parietotemporal cortical regions (BA 40, BA 22, and BA 42) before and after FEN activation compared to those without BPD. They also had less relative uptake in the anterior cingulate cortex (BA 32) at baseline compared to depressed patients without BPD and FEN abolished this difference. Impulsivity was positively correlated with rCMRglu in superior and middle frontal cortex (BA 6 and 44). Hostility was positively correlated with rCMRglu in temporal cortical regions (BA 21 and 22). In conclusions, borderline pathology in the context of a Major Depressive Disorder is associated with altered activity in parietotemporal and anterior cingulate cortical regions. Controlling for the presence of BPD in future imaging studies of mood disorders may elucidate similarities and differences in regional serotonergic function in these two often comorbid disorders.

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.

Brain perfusion SPECT in impulsivity-related personality disorders

BACKGROUND

Impulsive behaviours in patients with cluster B personality disorders are associated with low glucose metabolism and regional cerebral blood flow in the frontal cortex and subcortical structures. The aim of this study is to confirm the presence of a particular pattern of brain perfusion in a sample of borderline (BPD) and anti-social personality disorder (ASPD) patients using brain perfusion single photon emission computed tomography (SPECT).

METHODS

A brain perfusion SPECT study was performed in 37 patients with BPD or ASPD (and no Axis I diagnosis) and 34 healthy control participants. Data were acquired on a triple head Toshiba gamma camera. Scatter and attenuation correction was done. Reconstructed SPECT images were analyzed by Statistical Parametrical Mapping (SPM99).

RESULTS

There were no significant differences in age and gender distributions between the patients and the healthy controls. With regard to the functional imaging results, patients were characterized by a reduced regional cerebral blood flow (rCBF) in right temporal and prefrontal brain areas, including the right lateral temporal cortex (BA 21), the right frontopolar cortex (BA 10) and the right ventrolateral prefontal cortex (BA 47).

CONCLUSIONS

Patients with BPD and ASPD who showed impulsive behaviour have diminished rCBF in areas of the right prefrontal and temporal cortex.

Recent trends in the pharmacotherapy of personality disorders

This article reviews pharmacologic trials conducted between 2000 and 2003 directed at the treatment of borderline personality disorder, antisocial personality disorder, and schizotypal personality disorder. Atypical antipsychotics, antiepileptics, selective serotonin reuptake inhibitors, omega fatty acids, and opioid antagonists have all been studied in the treatment of borderline personality disorder with positive results. Atypical antipsychotics have been studied in both schizotypal personality disorder and antisocial personality disorder, again with encouraging outcome reports. Implications of personality changes in response to pharmacologic treatment are discussed. Based on the prevalence of these disorders and the burden they cause to afflicted individuals and society, further trials are unequivocally indicated.

Psychopharmacology of borderline personality disorder

Pharmacotherapy for patients with borderline personality disorder is directed against the psychobiology of cognitive-perceptual, affective, and impulsive-behavioral symptoms. A symptom-specific method using current empiric evidence for drug efficacy in each symptom domain is proposed. Drugs in each medication class have some potential utility against specific symptoms in patients with borderline personality disorder.

A brain MRI study in subjects with borderline personality disorder

BACKGROUND

There have been only a few brain computed tomography imaging studies, with mostly negative findings, in subjects with borderline personality disorder (BPD). This is the first MRI study which evaluated the structural abnormalities of the brain in subjects with the sole diagnosis of BPD.

METHODS

Twenty-five subjects with BPD were compared with age-, gender-matched healthy comparison subjects (n=25) on volumes of the frontal lobes, the temporal lobes, the lateral ventricles, and the cerebral hemispheres in brain magnetic resonance imaging.

RESULTS

Subjects with BPD had a significantly smaller frontal lobe compared to comparison subjects (multivariate regression analysis, t=2.225, df=46, P=0.031). There were no significant differences in volumes of the temporal lobes, the lateral ventricles, and the cerebral hemispheres between subjects with and without BPD.

LIMITATIONS

Strict inclusion and exclusion criteria employed in the present study may make it difficult to generalize our findings. The gray matter and white matter of the brain were not measured separately. Differences in head tilt during image acquisition were not corrected.

CONCLUSIONS

The current study reports a smaller frontal lobe volume on brain MRI in subjects with BPD compared with healthy comparison subjects. This finding may serve as a potentially useful biological variable that may allow for subtyping BPD.

Electroencephalographic abnormalities in borderline personality disorder

Epilepsy and non-localized brain dysfunction have been invoked, among others, as underlying factors in borderline personality disorder. We have recorded 58 electroencephalograms in 20 borderline patients, first after complete drug washout and then under carbamazepine or placebo double-blind treatment. Taking into account only definite abnormal tracings, we found a 40% incidence of abnormal diffuse slow activity. No patient disclosed focal or epileptiform EEG features. Carbamazepine did not appear to modify the electroencephalogram.

Brain glucose metabolism in borderline personality disorder

We searched for regional cerebral metabolic disturbances in patients with borderline personality disorder (BPD). Ten inpatients with BPD, no current DSM-IIIR Axis I diagnosis and free of any psychotropic substances, were compared with 15 age-matched control subjects using positron emission tomography with 2-deoxy-2-[18F]fluoro-D-glucose and semiquantitative analysis of regional glucose metabolic activity. We found relative hypometabolism in patients with borderline personality disorder at the level of the premotor and prefrontal cortical areas, the anterior part of the cingulate cortex and the thalamic, caudate and lenticular nuclei. This study shows significant cerebral metabolic disturbances in patients with borderline personality disorder. These metabolic disturbances, which are similar to some of those described in other psychiatric entities, may help to understand the characteristic clinical aspects of this disorder.