Deficient Amygdala Habituation to Threatening Stimuli in Borderline Personality Disorder Relates to Adverse Childhood Experiences

Facial emotion processing in patients with borderline personality disorder as compared with healthy controls: an fMRI and ECG study

BACKGROUND

Maladaptive behaviors and interpersonal difficulties in patients with borderline personality disorder (BPD) seem connected to biased facial emotion processing. This bias is often accompanied by heightened amygdala activity in patients with BPD as compared to healthy controls. However, functional magnetic resonance imaging (fMRI) studies exploring differences between patients and healthy controls in facial emotion processing have produced divergent results. The current study explored fMRI and heart rate variability (HRV) correlates of negative facial emotion processing in patients with BPD and healthy controls.

METHODS

The study included 30 patients with BPD (29 females; age: M = 24.22, SD = 5.22) and 30 healthy controls (29 females; M = 24.66, SD = 5.28). All participants underwent the "faces" task, an emotional face perception task, in an fMRI session simultaneously with ECG. In this task, participants are presented with emotional expressions of disgust, sadness, and fear (as a negative condition) and with the same pictures in a scrambled version (as a neutral condition).

RESULTS

We found no differences in brain activity between patients with BPD and healthy controls when processing negative facial expressions as compared to neutral condition. We observed activation in large-scale brain areas in both groups when presented with negative facial expressions as compared to neutral condition. Patients with BPD displayed lower HRV than healthy controls in both conditions. However, there were no significant associations between HRV and amygdala activity and BPD symptoms.

CONCLUSION

The results of this study indicate no abnormal brain activity during emotional facial processing in patients with BPD. This result contrasts with previous studies and more studies are needed to clarify the relationship between facial emotion processing and brain activity in patients with BPD. Possible reasons for the absence of brain activity differences are discussed in the study. Consistent with previous findings, patients showed lower HRV than healthy controls. However, HRV was not associated with amygdala activity and BPD symptoms.

Compassion Focused Group Psychotherapy for attachment and relational trauma: Engaging people with a diagnosis of personality disorder

OBJECTIVES

The research aimed to evaluate an exploratory Compassion Focused Group Psychotherapy Programme and the impact on participants' experiences of self-criticism, usage of services and general wellbeing. Participants included patients with a history of complex attachment and relational trauma (A&RT), who might attract a diagnosis of personality disorder.

DESIGN

This study utilised a quasi-experimental non-randomised within subject controlled design for the evaluation of the efficacy of the programme.

METHODS

Participants were recruited from tertiary care services. The programme consisted of a 12-week Preparation and Engagement intervention (PEG) which was Compassionate Mind Training and Psychoeducation, followed by a 40-week Compassion Focused Trauma Group intervention. The cohort was then followed up after 12 months during which period they received treatment as usual. A comprehensive selection of self-report measures was administered at various points during the therapeutic process and following completion of the group interventions.

RESULTS

The results of the research showed that the provision of a long-term, slow-paced, Compassion Focused Group Psychotherapy intervention, resulted in significant changes across all measures which were maintained at 12-month follow-up. These significant results were maintained following intention to treat and reliable change analyses. These data were supported by a significant reduction in service usage and a significant increase in engagement in employment and education.

CONCLUSIONS

This study has identified that within Compassion Focused Group Psychotherapy, there is a therapeutic process of establishing group-based safeness as a necessary precursor to cultivating compassion and reworking early shame-based trauma memories.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

A Neighborhood-level analysis of mental health distress and income inequality as quasi-longitudinal risk of reported COVID-19 infection and mortality outcomes in Chicago

Extant literature investigates the impact of COVID-19 on mental health outcomes, however there is a paucity of work examining mental health distress as a risk factor for COVID-19 outcomes. While systemic variables like income inequality relate to both mental health and COVID-19, more work is needed to test theoretically informed models including such variables. Using a social-ecological framework, we aimed to address these gaps in the literature by conducting a neighborhood-level analysis of potential mental health distress and systemic- (income inequality) level predictors of reported COVID-19 infection and mortality over time in Chicago. Neighborhood-level comparisons revealed differences in mental health distress, income inequality, and reported COVID-19 mortality, but not reported COVID-19 infection. Specifically, Westside and Southside neighborhoods generally reported higher levels of mental health distress and greater concentration of poverty. The Central neighborhood showed a decline in reported mortality rates over time. Multi-level negative binomial models established that Zip-codes with greater mental health distress were at increased reported COVID-19 infection risk, yet lower mortality risk; Zip-codes with more poverty were at increased reported COVID-19 infection risk, yet lower mortality risk; and Zip-codes with the highest percentage of People of Color were at decreased risk of reported COVID-19 mortality. Taken together, these findings substantiate Chicago neighborhood-level disparities in mental health distress, income inequality, and reported COVID-19 mortality; identify unique differential associations of mental health distress and income inequality to reported COVID-19 infection and reported mortality risk; and, offer an alternative lens towards understanding COVID-19 outcomes in terms of race/ethnicity.

A coordinate-based meta-analysis of human amygdala connectivity alterations related to early life adversities

By affecting core neurobiological systems early in development, early life adversities (ELAs) might confer latent vulnerability to future psychopathologies. This coordinate-based meta-analysis aims to identify significant convergent alterations in functional connectivity of the amygdala related to ELAs across resting-state and task-based fMRI-studies. Five electronic databases were systematically searched until 22 October 2020, retrieving 49 eligible studies (n = 3162 participants). Convergent alterations in functional connectivity related to ELAs between the amygdala and the anterior cingulate cortex (ACC) and left hippocampus were found. Sub-analyses based on hemisphere and direction showed that connectivity seeded in the right amygdala was affected and, moreover, revealed that connectivity with ACC was decreased. Analyses based on paradigm and age showed that amygdala-ACC coupling was altered during resting state and that amygdala-left hippocampus connectivity was mostly affected during task-based paradigms and in adult participants. While both regions showed altered connectivity during emotion processing and following adverse social postnatal experiences such as maltreatment, amygdala-ACC coupling was mainly affected when ELAs were retrospectively assessed through self-report. We show that ELAs are associated with altered functional connectivity of the amygdala with the ACC and hippocampus. As such, ELAs may embed latent vulnerability to future psychopathologies by systematically affecting important neurocognitive systems.

Reduced corticolimbic habituation to negative stimuli characterizes bipolar depressed suicide attempters

Suicide attempts in Bipolar Disorder are characterized by high levels of lethality and impulsivity. Reduced rates of amygdala and cortico-limbic habituation can identify a fMRI phenotype of suicidality in the disorder related to internal over-arousing states. Hence, we investigated if reduced amygdala and whole-brain habituation may differentiate bipolar suicide attempters (SA, n = 17) from non-suicide attempters (nSA, n = 57), and healthy controls (HC, n = 32). Habituation was assessed during a fMRI task including facial expressions of anger and fear and a control condition. Associations with suicidality and current depressive symptomatology were assessed, including machine learning procedure to estimate the potentiality of habituation as biomarker for suicidality. SA showed lower habituation compared to HC and nSA in several cortico-limbic areas, including amygdalae, cingulate and parietal cortex, insula, hippocampus, para-hippocampus, cerebellar vermis, thalamus, and striatum, while nSA displayed intermediate rates between SA and HC. Lower habituation rates in the amygdalae were also associated with higher depressive and suicidal current symptomatology. Machine learning on whole-brain and amygdala habituation differentiated SA vs. nSA with 94% and 69% of accuracy, respectively. Reduced habituation in cortico-limbic system can identify a candidate biomarker for attempting suicide, helping in detecting at-risk bipolar patients, and in developing new therapeutic interventions.

Early Social Adversity, Altered Brain Functional Connectivity, and Mental Health

Early adverse environmental exposures during brain development are widespread risk factors for the onset of severe mental disorders and strong and consistent predictors of stress-related mental and physical illness and reduced life expectancy. Current evidence suggests that early negative experiences alter plasticity processes during developmentally sensitive time windows and affect the regular functional interaction of cortical and subcortical neural networks. This, in turn, may promote a maladapted development with negative consequences on the mental and physical health of exposed individuals. In this review, we discuss the role of functional magnetic resonance imaging-based functional connectivity phenotypes as potential biomarker candidates for the consequences of early environmental exposures-including but not limited to-childhood maltreatment. We take an expanded concept of developmentally relevant adverse experiences from infancy over childhood to adolescence as our starting point and focus our review of functional connectivity studies on a selected subset of functional magnetic resonance imaging-based phenotypes, including connectivity in the limbic and within the frontoparietal as well as default mode networks, for which we believe there is sufficient converging evidence for a more detailed discussion in a developmental context. Furthermore, we address specific methodological challenges and current knowledge gaps that complicate the interpretation of early stress effects on functional connectivity and deserve particular attention in future studies. Finally, we highlight the forthcoming prospects and challenges of this research area with regard to establishing functional connectivity measures as validated biomarkers for brain developmental processes and individual risk stratification and as target phenotypes for mechanism-based interventions.

Reduced Real-life Affective Well-being and Amygdala Habituation in Unmedicated Community Individuals at Risk for Depression and Anxiety

BACKGROUND

Early identification of risk for depression and anxiety disorders is important for prevention, but real-life affective well-being and its biological underpinnings in the population remain understudied. Here, we combined methods from epidemiology, psychology, ecological momentary assessment, and functional magnetic resonance imaging to study real-life and neural affective functions in individuals with subclinical anxiety and depression from a population-based cohort of young adults.

METHODS

We examined psychological measures, real-life affective valence, functional magnetic resonance imaging amygdala habituation to negative affective stimuli, and the relevance of neural readouts for daily-life affective function in 132 non-help-seeking community individuals. We compared psychological and ecological momentary assessment measures of 61 unmedicated individuals at clinical risk for depression and anxiety (operationalized as subthreshold depression and anxiety symptoms or a former mood or anxiety disorder) with those of 48 nonrisk individuals and 23 persons with a mood or anxiety disorder. We studied risk-associated functional magnetic resonance imaging signals in subsamples with balanced sociodemographic and image quality parameters (26 nonrisk, 26 at-risk persons).

RESULTS

Compared with nonrisk persons, at-risk individuals showed significantly decreased real-life affective valence (p = .038), reduced amygdala habituation (familywise error-corrected p = .024, region of interest corrected), and an intermediate psychological risk profile. Amygdala habituation predicted real-life affective valence in control subjects but not in participants at risk (familywise error-corrected p = .005, region of interest corrected).

CONCLUSIONS

Our data suggest real-life and neural markers for affective alterations in unmedicated community individuals at risk for depression and anxiety and highlight the significance of amygdala habituation measures for the momentary affective experience in real-world environments.

Lack of amygdala habituation to negative emotional faces in alcohol use disorder and the relation to adverse childhood experiences

Aberrant limbic circuit reactivity to negative stimuli might be related to alterations in emotion processing and regulation in alcohol use disorder (AUD). The current study tested for the first time in AUD the hypothesis of aberrant amygdala habituation to repeated aversive stimuli-a robust and reliable neuroimaging marker for emotion processing. We explored the link between deficits in habituation to adverse childhood experience (ACE), a common risk factor for impaired emotion regulation and AUD. AUD individuals (N = 36) and healthy controls (HC; N = 26) participated in an observational case-control functional magnetic resonance imaging (fMRI) study. An established habituation index was used to investigate processing of aversive emotional faces of the amygdala. AUD individuals showed an overall deficit in amygdala habituation (right: t = 4.26, pFWE = 0.004; left: t = 4.79, pFWE ≤ 0.001). Amygdala habituation was significantly related to increased exposure to ACE in HC (t = 3.88, pFWE = 0.012), whereas this association was not observed in AUD individuals (T = 1.80, pFWE = 0.662). Further, a significant association between higher alcohol consumption and reduced amygdala habituation (right: R²  = -0.356, F = 8.736, p = 0.004; left: R²  = -0.309, F = 6.332, p = 0.015) was observed. We found novel evidence for neural alterations in emotion processing in AUD individuals, indexed by deficient amygdala habituation to negative emotional content. We replicated a prior report on a link between ACE and amygdala habituation, a well-established environmental risk factor for mental disorders and emotion dysregulation, in our control sample. Additionally, deficient amygdala habituation related to the amount of alcohol consumption in the overall sample might indicate a short-term substance effect.

A longitudinal mediation study of peer victimization and resting-state functional connectivity as predictors of development of adolescent psychopathology

Background

Peer victimization (PV) is associated with alterations in neural responses in regions subserving emotional regulatory processes and with increased risk of psychopathology during adolescence. The present study examined the longitudinal mediating effects of resting-state functional connectivity (rsFC) between adolescent PV and subsequent internalizing (depression and anxiety), and externalizing (conduct and hyperactivity/inattention) symptoms.

Methods

151 adolescents (baseline mean age 12-14; 54% males) were assessed and imaged three times during a five-year period. We focused on rsFC of a priori determined Regions-of-Interest (ROIs) guided by the literature (i.e., amygdala, anterior and posterior insula, anterior cingulate cortex, and medial prefrontal cortex). Multilevel mediation (MLM) analyses simultaneously examined the between-person, concurrent within-person, and lagged within-person associations between PV and internalizing/externalizing symptoms through changes in couplings of the amygdala with the other four ROIs. All models controlled for the effects of self-reported childhood maltreatment and sex differences.

Results

An increased rsFC of the amygdala-posterior insula significantly mediated the lagged within-person association of PV and internalizing symptoms (β = 0.144; 95% CI [0.018, 0.332]). This effect was significant regardless of childhood maltreatment, concurrent externalizing symptoms, and sex differences. The rsFC did not mediate the relationship between PV and externalizing symptoms.

Conclusions

Results of this study suggest that adolescent PV may lead to long-lasting maladaptive neural communication between emotional response and sensory perception of pain (i.e., bottom-up emotion regulation) and that these neural responses may serve as unique markers for increased internalizing symptoms that appear in later adolescence in peer-victimized youth. These findings have implications for interventions targeting internalizing symptoms in victimized adolescents.

Borderline Personality Disorder: Updates in a Postpandemic World

Progress in understanding borderline personality disorder has unfolded in the last decade, landing in a new COVID-19-influenced world. Borderline personality disorder is now firmly established as a valid diagnosis, distinct from its co-occurring mood, anxiety, trauma-related, and behavioral disorders. Further, it is also understood as a reflection of general personality dysfunction, capturing essential features shared among all personality disorders. Neuroimaging research, representing the vast neurobiological advances made in the last decade, illustrates that the disorder shares frontolimbic dysfunction with many psychiatric diagnoses but has a distinct signature of interpersonal and emotional hypersensitivity. This signature is the conceptual basis of the psychotherapies and clinical management approaches proven effective for the disorder. Medications remain adjunctive and are contraindicated by some guidelines internationally. Less invasive brain-based therapeutics show promise. The most significant change in the treatment landscape is a focus on briefer, less intensive formats of generalist management. Shorter variants of therapies, such as dialectical behavior therapy and mentalization-based treatment, are in the process of being shown to be adequately effective. Earlier intervention and greater emphasis on functional improvement are needed to more effectively curb the disabilities and risks of borderline personality disorder for patients and their families. Remote interventions show promise in broadening access to care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Lonely in the Dark: Trauma Memory and Sex-Specific Dysregulation of Amygdala Reactivity to Fear Signals

Loneliness exacerbates psychological distress and increases the risk of psychopathology after trauma exposure. However, it is still unclear whether a lack of social connectedness affects trauma-related intrusions and the neural processing of fear signals. Moreover, it is uncertain, whether loneliness plays a different role in women and men. A prestratification strategy is used and n = 47 (n = 20 women) healthy lonely individuals and n = 35 controls (n = 18 women) are recruited. Participants are exposed to an experimental trauma and evoked intrusive thoughts in daily life are monitored for three consecutive days. Functional magnetic resonance imaging is used to assess neural habituation to fearful faces and fear learning (conditioning and extinction) prior to trauma exposure. The results reveal a significant interaction between loneliness and sex such that loneliness is associated with more intrusions in men, but not in women. A similar pattern emerges at the neural level, with both reduced amygdala habituation to repeated fearful faces and amygdala hyperreactivity during the conditioning of fear signals in lonely men. The findings indicate that loneliness may confer vulnerability to intrusive memories after trauma exposure in healthy men and that this phenotype relates to altered limbic processing of fear signals.

A Mechanism-Based Approach to Anti-Aggression Psychotherapy in Borderline Personality Disorder: Group Treatment Affects Amygdala Activation and Connectivity

Aggression is highly prevalent in borderline personality disorder (BPD). Previous studies have identified specific biobehavioral mechanisms underlying aggression in BPD, threat sensitivity being among them. We composited the mechanism-based anti-aggression psychotherapy (MAAP) in order to target these specific mechanisms, and MAAP was found to be superior to non-specific supportive psychotherapy (NSSP) in reducing aggressive behavior. In the present study, we investigated whether underlying brain mechanisms expected to be involved were affected by MAAP. To this end, n = 33 patients with BPD and overt aggressive behavior (n = 20 in MAAP, n = 13 in NSSP) and n = 25 healthy participants took part in a functional magnetic resonance imaging emotional face-matching task before and after treatment, or at a similar time interval for controls. Overt aggressive behavior was assessed using the overt aggression scale, modified. Results showed a decrease in amygdala activation in response to facial stimuli after MAAP, whereas an increase in amygdala activation was found after NSSP. Furthermore, in the MAAP group, connectivity between amygdala and dorsomedial prefrontal cortex increased from pre- to post-treatment compared to the NSSP group. Hence, the results suggest an impact of MAAP on brain mechanisms underlying the salience circuit in response to threat cues.

Imaging associations of self-injurious behaviours amongst patients with Borderline Personality Disorder: A mini-review

BACKGROUND

Borderline Personality Disorder (BPD) is a severe and disabling psychiatric syndrome, frequently associated with self-injurious behaviours (SIB). In recent years, functional magnetic resonance imaging (fMRI) investigations have tried to identify alterations associated with SIB amongst BPD patients, in order to better delineate possible neurobiological underpinnings of these manifestations. In this mini-review, we aimed at summarizing fMRI studies exploring patterns of neural activation associated with SIB in BPD patients.

METHODS

Literature searches on PubMed, Psych-Info and Embase databases were performed for all fMRI studies including adult patients with BPD and SIB undergoing different tasks, including painful or thermic stimulation, affective stimulation through the presentation of picturesor the recollection of personal memories as well as tasks that evaluate sustained attention and impulsivity, and reward processing. Thirteen relevant papers were considered eligible for the present review.

RESULTS

Patients with BPD and SIB, compared to HC, showed prefrontal, nucleus accumbens overactivation and amygdala deactivation during pain stimulation. During negative affective stimulation, BPD patients showed a hyperactivation of the amygdala and a hypoactivation of the orbitofrontal cortex (OFC), which was also found to be enhanced during a gambling task and during a recalling of aversive memories. In contrast, during cognitive tasks with negative affective interference, BPD patients showed hypoactivation of OFC, anterior cingulated cortex, and basal ganglia.

LIMITATIONS

The limited number of studies and the heterogeneity regarding the fMRI tasks employed allowed only suggestive conclusions.

CONCLUSIONS

The reviewed fMRI studies highlighted that BPD patients with a history of SIB showed altered brain activity, compared to HC, in regions involved in inhibitory cognitive processes and affect regulation, which may in turn, explain the overwhelming emotional experiences eliciting SIB in these patients.

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.

[Neurobiological principles of borderline personality disorder: integration into the ICD-11 model of personality disorders]

BACKGROUND

Borderline personality disorder (BPD) is a severe mental disorder associated with far-reaching impairments in the self and interpersonal functioning. The broad database has contributed to the fact that BPD remains the only categorical personality diagnosis in ICD-11, even if coupled to the determination of the severity of impairments. Nevertheless, we need to deal with a dimensional conceptualization of personality disorders-which is also supported by neuroscientific findings-at the latest in 2022 when the ICD-11 comes into effect .

OBJECTIVE

This narrative review provides an overview of neuroscientific findings regarding impairments in self and interpersonal functioning in patients with BPD.

RESULTS

Alterations in the medial prefrontal cortex, temporoparietal junction and precuneus mediate deficits in self-referential thought processes and the mentalization of emotions and intentions of others. Enhanced connectivity between the amygdala and midline structures is associated with hypermentalization. At the same time, elevated insula activation seems to underlie the strengthened nonreflective parts of feelings of other people. Frontolimbic alterations are transdiagnostically associated with deficient emotional regulation and negative affectivity and alterations in reward and cognitive control regions are related to impulsivity.

CONCLUSION

Neuroscientific findings help to have a better understanding of the underlying mechanisms of central functional impairments in BPD and can support the transition to ICD-11 as well as the implementation of new interventions.

Complex PTSD and borderline personality disorder

BACKGROUND

This article builds on a previous review (Ford and Courtois, Borderline Personal Disord Emot Dysregul 1:9, 2014) which concluded that complex posttraumatic stress disorder (cPTSD) could not be conceptualized as a sub-type of either PTSD or BPD. Recent research is reviewed that extends and clarifies the still nascent understanding of the relationship between cPTSD and BPD.

MAIN BODY

The circumscribed formulation of adult cPTSD that has been developed, validated, and included in the 11th Edition of the International Classification of Diseases has spurred research aimed at differentiating cPTSD and BPD both descriptively and empirically. A newly validated Developmental Trauma Disorder (DTD) syndrome for children and adolescents provides a basis for systematic research on the developmental course and origins of adult cPTSD and BPD. This review summarizes recent empirical findings regarding BPD, PTSD, and cPTSD in terms of: (1) prevalence and comorbidity; (2) clinical phenomenology; (3) traumatic antecedents; (4) psychobiology; (5) emotion dysregulation; (6) dissociation; and (7) empirically supported approaches to clinical assessment and psychotherapeutic treatment.

CONCLUSION

The evidence suggests that PTSD, cPTSD, and BPD are potentially comorbid but distinct syndromes. A hypothesis is advanced to stimulate scientific research and clinical innovation defining and differentiating the disorders, positing that they may represent a continuum paralleling the classic conceptualization of the stress response, with dissociation potentially involved in each disorder.

Dissociation in Borderline Personality Disorder: Recent Experimental, Neurobiological Studies, and Implications for Future Research and Treatment

PURPOSE OF REVIEW

The aim of this review article is to give an overview over recent experimental neurobiological research on dissociation in borderline personality disorder (BPD), in order to inform clinicians and to stimulate further research. First, we introduce basic definitions and models that conceptualize dissociation from a transdiagnostic perspective. Then, we discuss recent findings in BPD.

RECENT FINDINGS

Stress-related dissociation is a key symptom of BPD, closely linked to other core domains of the disorder (emotion dysregulation, identity disturbances, and interpersonal disturbances). The understanding of neurobiological correlates of dissociation across different psychiatric disorders (e.g., dissociative disorders, post-traumatic stress disorder) is steadily increasing. At the same time, studies explicitly focusing on dissociation in BPD are still scarce. There is evidence for adverse effects of dissociation on affective-cognitive functioning (e.g., interference inhibition), body perception, and psychotherapeutic treatment response in BPD. On the neural level, increased activity in frontal regions (e.g., inferior frontal gyrus) and temporal areas (e.g., inferior and superior temporal gyrus) during symptom provocation tasks and during resting state was observed, although findings are still diverse and need to be replicated. Conceptual differences and methodological differences in study designs and sample characteristics (e.g., comorbidities, trauma history) hinder a straightforward interpretation and comparison of studies. Given the potentially detrimental impact of dissociation in BPD, more research on the topic is strongly needed to deepen the understanding of this complex clinical condition.

An eye-tracking study of interpersonal threat sensitivity and adverse childhood experiences in borderline personality disorder

BACKGROUND

Previous eye-tracking studies provide preliminary evidence for a hypersensitivity to negative, potentially threatening interpersonal cues in borderline personality disorder (BPD). From an etiological point of view, such interpersonal threat hypersensitivity might be explained by a biological vulnerability along with a history of early life adversities. The objective of the current study was to investigate interpersonal threat hypersensitivity and its association with adverse childhood experiences (ACE) in patients with BPD employing eye-tracking technology.

METHODS

We examined a sample of 46 unmedicated, adult female patients with BPD and 25 healthy female volunteers, matched on age and intelligence, with a well-established emotion classification paradigm with angry, fearful, happy, and neutral facial expressions. ACE were assessed retrospectively with the Childhood Trauma Questionnaire.

RESULTS

Patients as compared to healthy volunteers reflexively directed their gaze more quickly towards the eyes of emotional and neutral faces and did not adapt their fixation patterns according to the facial expression presented. Misclassifying emotional and neutral faces as angry correlated positively with the patients' self-reported ACE.

CONCLUSIONS

Building on and extending earlier findings, our results are likely to suggest a visual hypervigilance towards the eyes of emotional and neutral facial expressions and a childhood trauma-related anger bias in patients with BPD. Given the lack of a clinical control group, the question whether these findings are specific for BPD has to remain open. Thus, further research is needed to elucidate the specificity of altered visual attention allocation and the role of ACE in anger recognition in patients with BPD.

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

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

Evidence for Altered Neural Processing in Patients With Borderline Personality Disorder

Abstract. Borderline personality disorder (BPD) is characterized by difficulties in emotion regulation, self-identity disturbances, self-injurious behavior, and reduced inhibitory control. Event-related potential (ERP) studies have sought to reveal the neural correlates of cognitive distortions and behavioral alterations in BPD. The article presents an overview of the existing ERP literature pertaining to BPD and discusses whether any one of the electrophysiological findings could serve as a reliable and specific marker for BPD. In short, ERP studies investigating P300 tentatively suggest impaired inhibitory control. Moreover, reduced error- and feedback-related processing and impaired response inhibition seem to be associated with impulsivity and risk-taking behavior in BPD patients. However, these findings are not specific for BPD. Regarding emotional and self-referential information processing, individuals with BPD display heightened vigilance toward social threat impacting their cognitive performance in various social-cognitive tasks demonstrating alterations of early negative and late positive potentials. These multifaceted electrophysiological alterations may be attributed to dysfunctional activity and connectivity of frontal brain regions and the limbic system.

The identification of a risk profile for young people with borderline personality pathology: a review of recent literature

The shift towards early intervention in borderline personality disorder (BPD) has introduced a clinical staging approach in the treatment for young persons with BPD. Complementary to staging is profiling: the identification of psychological, social and biological risk variables that may predict prognosis. The aim of this paper is to provide a risk profile for BPD by systematically reviewing literature on potential risk markers for poor prognosis for BPD. An extensive literature search revealed evidence for seven categories of risk factors: adverse childhood experiences, BPD symptom profile, associated mental disorders, personality impairments and traits, current interpersonal context, biological disposition and socio-demographics. Including these markers within the current staging approach, to compose individual risk profiles for poor BPD prognosis, may assist in personalizing treatment for young people with BPD and in refining research protocols for treatment outcome studies.

Genetic modulation of facial emotion recognition in borderline personality disorder

Facial emotion recognition (FER) has been described to be impaired in borderline personality disorder (BPD), especially for neutral faces. Genetic modulation of FER has been studied in healthy individuals and some psychiatric conditions, but no genetic association studies have been conducted in BPD hitherto. The main objective of our study was to explore the influence of the serotonin-transporter-linked promoter region (5HTTLPR) and catechol-o-methyltransferase (COMT) Val158Met on facial emotion processing among BPD patients. To that end, seventy-six BPD outpatients were asked to complete a computer-based facial affect recognition task, representing four emotions (neutral, happy, fearful or angry). Accuracy of FER and perceptual biases were calculated. The 5HTTLPR and COMT Val158Met polymorphisms were genotyped using saliva samples. Individuals with the high-activity serotonin-transporter genotype and those with the low-activity COMT genotype had significantly more difficulties identifying neutral faces; the former showed stronger bias to perceive neutral faces as happy, and the latter, neutral faces as fearful. Interestingly, the perceptual biases observed in our patients are similar to previous reports in healthy individuals. The authors propose that the ability to accurately recognize neutral faces might be a possible endophenotype of BPD. Sex-genotype interactions were also observed in relation to angry faces and 5HTTLPR, and neutral faces and COMT Val158Met polymorphisms, in line with sex-related differences previously described for both polymorphisms in relation to FER and other cognitive and behavioral outcomes. The impact of inaccurate FER on psychosocial functioning and potential interventions are also discussed.