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Morawetz C, Basten U. Neural underpinnings of individual differences in emotion regulation: A systematic review. Neurosci Biobehav Rev 2024; 162:105727. [PMID: 38759742 DOI: 10.1016/j.neubiorev.2024.105727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/06/2024] [Accepted: 05/13/2024] [Indexed: 05/19/2024]
Abstract
This review synthesises individual differences in neural processes related to emotion regulation (ER). It comprises individual differences in self-reported and physiological regulation success, self-reported ER-related traits, and demographic variables, to assess their correlation with brain activation during ER tasks. Considering region-of-interest (ROI) and whole-brain analyses, the review incorporated data from 52 functional magnetic resonance imaging studies. Results can be summarized as follows: (1) Self-reported regulation success (assessed by emotional state ratings after regulation) and self-reported ER-related traits (assessed by questionnaires) correlated with brain activity in the lateral prefrontal cortex. (2) Amygdala activation correlated with ER-related traits only in ROI analyses, while it was associated with regulation success in whole-brain analyses. (3) For demographic and physiological measures, there was no systematic overlap in effects reported across studies. In showing that individual differences in regulation success and ER-related traits can be traced back to differences in the neural activity of brain regions associated with emotional reactivity (amygdala) and cognitive control (lateral prefrontal cortex), our findings can inform prospective personalised intervention models.
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Affiliation(s)
| | - Ulrike Basten
- Department of Psychology, RPTU Kaiserslautern-Landau, Germany
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Zopfs M, Jindrová M, Gurevitch G, Keynan JN, Hendler T, Baumeister S, Aggensteiner PM, Cornelisse S, Brandeis D, Schmahl C, Paret C. Amygdala-related electrical fingerprint is modulated with neurofeedback training and correlates with deep-brain activation: proof-of-concept in borderline personality disorder. Psychol Med 2024; 54:1651-1660. [PMID: 38131344 DOI: 10.1017/s0033291723003549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND The modulation of brain circuits of emotion is a promising pathway to treat borderline personality disorder (BPD). Precise and scalable approaches have yet to be established. Two studies investigating the amygdala-related electrical fingerprint (Amyg-EFP) in BPD are presented: one study addressing the deep-brain correlates of Amyg-EFP, and a second study investigating neurofeedback (NF) as a means to improve brain self-regulation. METHODS Study 1 combined electroencephalography (EEG) and simultaneous functional magnetic resonance imaging to investigate the replicability of Amyg-EFP-related brain activation found in the reference dataset (N = 24 healthy subjects, 8 female; re-analysis of published data) in the replication dataset (N = 16 female individuals with BPD). In the replication dataset, we additionally explored how the Amyg-EFP would map to neural circuits defined by the research domain criteria. Study 2 investigated a 10-session Amyg-EFP NF training in parallel to a 12-weeks residential dialectical behavior therapy (DBT) program. Fifteen patients with BPD completed the training, N = 15 matched patients served as DBT-only controls. RESULTS Study 1 replicated previous findings and showed significant amygdala blood oxygenation level dependent activation in a whole-brain regression analysis with the Amyg-EFP. Neurocircuitry activation (negative affect, salience, and cognitive control) was correlated with the Amyg-EFP signal. Study 2 showed Amyg-EFP modulation with NF training, but patients received reversed feedback for technical reasons, which limited interpretation of results. CONCLUSIONS Recorded via scalp EEG, the Amyg-EFP picks up brain activation of high relevance for emotion. Administering Amyg-EFP NF in addition to standardized BPD treatment was shown to be feasible. Clinical utility remains to be investigated.
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Affiliation(s)
- Malte Zopfs
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Miroslava Jindrová
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Guy Gurevitch
- Sagol Brain Institute, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Jackob N Keynan
- Brain Stimulation Lab, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Talma Hendler
- Sagol Brain Institute, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- School of Psychological Sciences and Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
| | - Sarah Baumeister
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Pascal-M Aggensteiner
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Sven Cornelisse
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Daniel Brandeis
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Christian Schmahl
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Christian Paret
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
- Sagol Brain Institute, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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Morrissey G, Tsuchiyagaito A, Takahashi T, McMillin J, Aupperle RL, Misaki M, Khalsa SS. Could neurofeedback improve therapist-patient communication? Considering the potential for neuroscience informed examinations of the psychotherapeutic relationship. Neurosci Biobehav Rev 2024; 161:105680. [PMID: 38641091 DOI: 10.1016/j.neubiorev.2024.105680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 03/22/2024] [Accepted: 04/16/2024] [Indexed: 04/21/2024]
Abstract
Empathic communication between a patient and therapist is an essential component of psychotherapy. However, finding objective neural markers of the quality of the psychotherapeutic relationship have been elusive. Here we conceptualize how a neuroscience-informed approach involving real-time neurofeedback, facilitated via existing functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) technologies, could provide objective information for facilitating therapeutic rapport. We propose several neurofeedback-assisted psychotherapy (NF-AP) approaches that could be studied as a way to optimize the experience of the individual patient and therapist across the spectrum of psychotherapeutic treatment. Finally, we consider how the possible strengths of these approaches are balanced by their current limitations and discuss the future prospects of NF-AP.
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Affiliation(s)
| | - Aki Tsuchiyagaito
- Laureate Institute for Brain Research, Tulsa, OK, USA; Oxley College of Health and Natural Sciences, University of Tulsa, Tulsa, OK, USA
| | - Toru Takahashi
- Laureate Institute for Brain Research, Tulsa, OK, USA; Japan Society for the Promotion of Science, Chiyoda-ku, Tokyo, Japan
| | - John McMillin
- Advocate Medical Group, Downers Grove, IL, USA; Department of Psychiatry, University of Oklahoma-Tulsa, Tulsa, OK, USA
| | - Robin L Aupperle
- Laureate Institute for Brain Research, Tulsa, OK, USA; Oxley College of Health and Natural Sciences, University of Tulsa, Tulsa, OK, USA
| | - Masaya Misaki
- Laureate Institute for Brain Research, Tulsa, OK, USA; Oxley College of Health and Natural Sciences, University of Tulsa, Tulsa, OK, USA
| | - Sahib S Khalsa
- Laureate Institute for Brain Research, Tulsa, OK, USA; Oxley College of Health and Natural Sciences, University of Tulsa, Tulsa, OK, USA.
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Fine NB, Neuman Fligelman E, Carlton N, Bloch M, Hendler T, Helpman L, Seligman Z, Armon DB. Integration of limbic self-neuromodulation with psychotherapy for complex post-traumatic stress disorder: treatment rationale and case study. Eur J Psychotraumatol 2024; 15:2256206. [PMID: 38166532 PMCID: PMC10769120 DOI: 10.1080/20008066.2023.2256206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 07/24/2023] [Indexed: 01/04/2024] Open
Abstract
Treatment Rationale: Exposure to repeated sexual trauma, particularly during childhood, often leads to protracted mental health problems. Childhood adversity is specifically associated with complex posttraumatic stress disorder (PTSD) presentation, which is particularly tenacious and treatment refractory, and features severe emotion dysregulation. Augmentation approaches have been suggested to enhance treatment efficacy in PTSD thus integrating first-line psychotherapy with mechanistically informed self-neuromodulation procedures (i.e. neurofeedback) may pave the way to enhanced clinical outcomes. A central neural mechanism of PTSD and emotion dysregulation involves amygdala hyperactivity that can be volitionally regulated by neurofeedback. We outline a treatment rationale that includes a detailed justification for the potential of combining psychotherapy and NF and delineate mechanisms of change. We illustrate key processes of reciprocal interactions between neurofeedback engagement and therapeutic goals.Case Study: We describe a clinical case of a woman with complex PTSD due to early and repetitive childhood sexual abuse using adjunctive neurofeedback as an augmentation to an ongoing, stable, traditional treatment plan. The woman participated in (a) ten sessions of neurofeedback by the use of an fMRI-inspired EEG model of limbic related activity (Amygdala Electrical-Finger-Print; AmygEFP-NF), (b) traditional weekly individual psychotherapy, (c) skills group. Before and after NF training period patient was blindly assessed for PTSD symptoms, followed by a 1, 3- and 6-months self-report follow-up. We demonstrate mechanisms of change as well as the clinical effectiveness of adjunctive treatment as indicated by reduced PTSD symptoms and improved daily functioning within this single case.Conclusions: We outline an integrative neuropsychological framework for understanding the unique mechanisms of change conferring value to conjoining NF applications with trauma-focused psychotherapy in complex PTSD.
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Affiliation(s)
- Naomi B. Fine
- Faculty of Social Sciences, School of Psychological Sciences, Tel-Aviv University, Tel-Aviv, Israel
- Sagol Brain Institute Tel-Aviv, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Ellie Neuman Fligelman
- Lotem Center for Treatment of Sexual Trauma, Department of Psychiatry, Sourasky Medical Center, Tel Aviv, Israel
| | - Nora Carlton
- Lotem Center for Treatment of Sexual Trauma, Department of Psychiatry, Sourasky Medical Center, Tel Aviv, Israel
| | - Miki Bloch
- Psychiatric Department, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Talma Hendler
- Faculty of Social Sciences, School of Psychological Sciences, Tel-Aviv University, Tel-Aviv, Israel
- Sagol Brain Institute Tel-Aviv, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
| | - Liat Helpman
- Psychiatric Department, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Department of Counseling and Human Development, University of Haifa, Haifa, Israel
| | - Zivya Seligman
- Lotem Center for Treatment of Sexual Trauma, Department of Psychiatry, Sourasky Medical Center, Tel Aviv, Israel
| | - Daphna Bardin Armon
- Lotem Center for Treatment of Sexual Trauma, Department of Psychiatry, Sourasky Medical Center, Tel Aviv, Israel
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Pamplona GSP, Heldner J, Langner R, Koush Y, Michels L, Ionta S, Salmon CEG, Scharnowski F. Preliminary findings on long-term effects of fMRI neurofeedback training on functional networks involved in sustained attention. Brain Behav 2023; 13:e3217. [PMID: 37594145 PMCID: PMC10570501 DOI: 10.1002/brb3.3217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 07/25/2023] [Accepted: 07/29/2023] [Indexed: 08/19/2023] Open
Abstract
INTRODUCTION Neurofeedback based on functional magnetic resonance imaging allows for learning voluntary control over one's own brain activity, aiming to enhance cognition and clinical symptoms. We previously reported improved sustained attention temporarily by training healthy participants to up-regulate the differential activity of the sustained attention network minus the default mode network (DMN). However, the long-term brain and behavioral effects of this training have not yet been studied. In general, despite their relevance, long-term learning effects of neurofeedback training remain under-explored. METHODS Here, we complement our previously reported results by evaluating the neurofeedback training effects on functional networks involved in sustained attention and by assessing behavioral and brain measures before, after, and 2 months after training. The behavioral measures include task as well as questionnaire scores, and the brain measures include activity and connectivity during self-regulation runs without feedback (i.e., transfer runs) and during resting-state runs from 15 healthy individuals. RESULTS Neurally, we found that participants maintained their ability to control the differential activity during follow-up sessions. Further, exploratory analyses showed that the training increased the functional connectivity between the DMN and the occipital gyrus, which was maintained during follow-up transfer runs but not during follow-up resting-state runs. Behaviorally, we found that enhanced sustained attention right after training returned to baseline level during follow-up. CONCLUSION The discrepancy between lasting regulation-related brain changes but transient behavioral and resting-state effects raises the question of how neural changes induced by neurofeedback training translate to potential behavioral improvements. Since neurofeedback directly targets brain measures to indirectly improve behavior in the long term, a better understanding of the brain-behavior associations during and after neurofeedback training is needed to develop its full potential as a promising scientific and clinical tool.
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Affiliation(s)
- Gustavo Santo Pedro Pamplona
- Sensory‐Motor Laboratory (SeMoLa), Jules‐Gonin Eye Hospital/Fondation Asile des AveuglesDepartment of Ophthalmology/University of LausanneLausanneSwitzerland
- InBrain Lab, Department of PhysicsUniversity of Sao PauloRibeirao PretoBrazil
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric HospitalUniversity of ZurichZurichSwitzerland
- Rehabilitation Engineering Laboratory (RELab), Department of Health Sciences and TechnologyETH ZurichZurichSwitzerland
| | - Jennifer Heldner
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric HospitalUniversity of ZurichZurichSwitzerland
| | - Robert Langner
- Institute of Systems NeuroscienceHeinrich Heine University DusseldorfDusseldorfGermany
- Institute of Neuroscience and Medicine, Brain & Behaviour (INM‐7)Research Centre JulichJulichGermany
| | - Yury Koush
- Department of Radiology and Biomedical Imaging, Yale School of MedicineYale UniversityNew HavenConnecticutUSA
| | - Lars Michels
- Department of NeuroradiologyUniversity Hospital ZurichZurichSwitzerland
- Neuroscience Center ZurichUniversity of Zurich and Swiss Federal Institute of TechnologyZurichSwitzerland
| | - Silvio Ionta
- Sensory‐Motor Laboratory (SeMoLa), Jules‐Gonin Eye Hospital/Fondation Asile des AveuglesDepartment of Ophthalmology/University of LausanneLausanneSwitzerland
| | | | - Frank Scharnowski
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric HospitalUniversity of ZurichZurichSwitzerland
- Neuroscience Center ZurichUniversity of Zurich and Swiss Federal Institute of TechnologyZurichSwitzerland
- Department of Cognition, Emotion, and Methods in Psychology, Faculty of PsychologyUniversity of ViennaViennaAustria
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Babaskina L, Afanasyeva N, Semyonkina M, Myasnyankina O, Sushko N. Effectiveness of Neurofeedback Training for Patients with Personality Disorders: A Systematic Review. IRANIAN JOURNAL OF PSYCHIATRY 2023; 18:352-361. [PMID: 37575604 PMCID: PMC10422943 DOI: 10.18502/ijps.v18i3.13014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/15/2023] [Accepted: 02/22/2023] [Indexed: 08/15/2023]
Abstract
Objective: Personality disorders are serious psychiatric conditions, and some studies have examined neurofeedback training as a potential alternative treatment to improve cognitive and clinical symptoms in patients with such disorders. Here, we aimed to provide a first systematic review of such trials and present existing evidence regarding this treatment for individuals with personality disorders. Method : A systematic search of peer-reviewed English journal articles was conducted for this study to identify original studies on fMRI and EEG neurofeedback treatment protocols in patients with personality disorders up to January 2023. PubMed, Web of Science, ProQuest, Cochrane Library, and Google Scholar databases were queried through the keywords "neurofeedback," "biofeedback," and "personality disorder," as well as their related Mesh synonyms. Results: Totally, five studies were included in our systematic review. Two studies utilized EEG neurofeedback protocols, while three articles used real-time fMRI neurofeedback protocols. The types of studies were non-randomized, not-blinded case reports, case series, and single-arm trials with a high risk of bias. EEG neurofeedback protocols applied more training sessions and reported improvements in patients' neuropsychological and behavioral functions after treatment. Furthermore, fMRI-based neurofeedback studies reported neurophysiological changes, such as a shift in vmPFC-amygdala connectivity, towards healthy states following treatment. Moreover, behavioral symptoms of patients were reported to be improved after fMRI neurofeedback. Conclusion: Neurofeedback studies investigating this therapeutic technique for personality disorders are still very preliminary, and no strict conclusions can be drawn at this time. Therefore, further basic and clinical investigations are required to address several open methodological and technical questions and establish consensus and standardization, which will eventually lead to translational works.
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Zhao Z, Duek O, Seidemann R, Gordon C, Walsh C, Romaker E, Koller WN, Horvath M, Awasthi J, Wang Y, O'Brien E, Fichtenholtz H, Hampson M, Harpaz-Rotem I. Amygdala downregulation training using fMRI neurofeedback in post-traumatic stress disorder: a randomized, double-blind trial. Transl Psychiatry 2023; 13:177. [PMID: 37230984 PMCID: PMC10209552 DOI: 10.1038/s41398-023-02467-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/19/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023] Open
Abstract
Hyperactivation of amygdala is a neural marker for post-traumatic stress disorder (PTSD) and improvement in control over amygdala activity has been associated with treatment success in PTSD. In this randomized, double-blind clinical trial we evaluated the efficacy of a real-time fMRI neurofeedback intervention designed to train control over amygdala activity following trauma recall. Twenty-five patients with PTSD completed three sessions of neurofeedback training in which they attempted to downregulate the feedback signal after exposure to personalized trauma scripts. For subjects in the active experimental group (N = 14), the feedback signal was from a functionally localized region of their amygdala associated with trauma recall. For subjects in the control group (N = 11), yoked-sham feedback was provided. Changes in control over the amygdala and PTSD symptoms served as the primary and secondary outcome measurements, respectively. We found significantly greater improvements in control over amygdala activity in the active group than in the control group 30-days following the intervention. Both groups showed improvements in symptom scores, however the symptom reduction in the active group was not significantly greater than in the control group. Our finding of greater improvement in amygdala control suggests potential clinical application of neurofeedback in PTSD treatment. Thus, further development of amygdala neurofeedback training in PTSD treatment, including evaluation in larger samples, is warranted.
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Affiliation(s)
- Zhiying Zhao
- Centre for Cognitive and Brain Sciences, University of Macau, Macau SAR, China
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Or Duek
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- National Center for PTSD, West Haven, CT, USA
| | - Rebecca Seidemann
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- National Center for PTSD, West Haven, CT, USA
| | - Charles Gordon
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- National Center for PTSD, West Haven, CT, USA
| | - Christopher Walsh
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Emma Romaker
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - William N Koller
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Mark Horvath
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- National Center for PTSD, West Haven, CT, USA
| | - Jitendra Awasthi
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Yao Wang
- Centre for Cognitive and Brain Sciences, University of Macau, Macau SAR, China
| | - Erin O'Brien
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- National Center for PTSD, West Haven, CT, USA
| | - Harlan Fichtenholtz
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- Department of Psychology, Keene State College, Keene, NH, USA
| | - Michelle Hampson
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA.
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA.
- Department of Biomedical Engineering, Yale University School of Medicine, New Haven, CT, USA.
| | - Ilan Harpaz-Rotem
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.
- National Center for PTSD, West Haven, CT, USA.
- Department of Psychology and Wu Tsai Institute, Yale University, New Haven, CT, USA.
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Jaeckle T, Williams SCR, Barker GJ, Basilio R, Carr E, Goldsmith K, Colasanti A, Giampietro V, Cleare A, Young AH, Moll J, Zahn R. Self-blame in major depression: a randomised pilot trial comparing fMRI neurofeedback with self-guided psychological strategies. Psychol Med 2023; 53:2831-2841. [PMID: 34852855 PMCID: PMC10235657 DOI: 10.1017/s0033291721004797] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 02/19/2021] [Accepted: 11/02/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Overgeneralised self-blame and worthlessness are key symptoms of major depressive disorder (MDD) and have previously been associated with self-blame-selective changes in connectivity between right superior anterior temporal lobe (rSATL) and subgenual frontal cortices. Another study showed that remitted MDD patients were able to modulate this neural signature using functional magnetic resonance imaging (fMRI) neurofeedback training, thereby increasing their self-esteem. The feasibility and potential of using this approach in symptomatic MDD were unknown. METHOD This single-blind pre-registered randomised controlled pilot trial probed a novel self-guided psychological intervention with and without additional rSATL-posterior subgenual cortex (BA25) fMRI neurofeedback, targeting self-blaming emotions in people with insufficiently recovered MDD and early treatment-resistance (n = 43, n = 35 completers). Participants completed three weekly self-guided sessions to rebalance self-blaming biases. RESULTS As predicted, neurofeedback led to a training-induced reduction in rSATL-BA25 connectivity for self-blame v. other-blame. Both interventions were safe and resulted in a 46% reduction on the Beck Depression Inventory-II, our primary outcome, with no group differences. Secondary analyses, however, revealed that patients without DSM-5-defined anxious distress showed a superior response to neurofeedback compared with the psychological intervention, and the opposite pattern in anxious MDD. As predicted, symptom remission was associated with increases in self-esteem and this correlated with the frequency with which participants employed the psychological strategies in daily life. CONCLUSIONS These findings suggest that self-blame-rebalance neurofeedback may be superior over a solely psychological intervention in non-anxious MDD, although further confirmatory studies are needed. Simple self-guided strategies tackling self-blame were beneficial, but need to be compared against treatment-as-usual in further trials. https://doi.org/10.1186/ISRCTN10526888.
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Affiliation(s)
- Tanja Jaeckle
- Department of Psychological Medicine, Centre for Affective Disorders, London, UK
| | - Steven C. R. Williams
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Gareth J. Barker
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Rodrigo Basilio
- Cognitive and Behavioral Neuroscience Unit and Neuroinformatics Workgroup, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
| | - Ewan Carr
- Department of Biostatistics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Kimberley Goldsmith
- Department of Biostatistics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Alessandro Colasanti
- Department of Psychological Medicine, Centre for Affective Disorders, London, UK
| | - Vincent Giampietro
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Anthony Cleare
- Department of Psychological Medicine, Centre for Affective Disorders, London, UK
| | - Allan H. Young
- Department of Psychological Medicine, Centre for Affective Disorders, London, UK
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent, BR3 3BX, UK
| | - Jorge Moll
- Cognitive and Behavioral Neuroscience Unit and Neuroinformatics Workgroup, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
| | - Roland Zahn
- Department of Psychological Medicine, Centre for Affective Disorders, London, UK
- Cognitive and Behavioral Neuroscience Unit and Neuroinformatics Workgroup, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent, BR3 3BX, UK
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Davanzo A, D Huart D, Seker S, Moessner M, Zimmermann R, Schmeck K, Behn A. Study Features and Response Compliance in Ecological Momentary Assessment Research in Borderline Personality Disorder: Systematic Review and Meta-analysis. J Med Internet Res 2023; 25:e44853. [PMID: 36920466 PMCID: PMC10131785 DOI: 10.2196/44853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/17/2023] [Accepted: 01/31/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Borderline personality disorder (BPD) is characterized by frequent and intense moment-to-moment changes in affect, behavior, identity, and interpersonal relationships, which typically result in significant and negative deterioration of the person's overall functioning and well-being. Measuring and characterizing the rapidly changing patterns of instability in BPD dysfunction as they occur in a person's daily life can be challenging. Ecological momentary assessment (EMA) is a method that can capture highly dynamic processes in psychopathology research and, thus, is well suited to study intense variability patterns across areas of dysfunction in BPD. EMA studies are characterized by frequent repeated assessments that are delivered to participants in real-life, real-time settings using handheld devices capable of registering responses to short self-report questions in daily life. Compliance in EMA research is defined as the proportion of prompts answered by the participant, considering all planned prompts sent. Low compliance with prompt schedules can compromise the relative advantages of using this method. Despite the growing EMA literature on BPD in recent years, findings regarding study design features that affect compliance with EMA protocols have not been compiled, aggregated, and estimated. OBJECTIVE This systematic meta-analytic review aimed to investigate the relationship between study design features and participant compliance in EMA research of BPD. METHODS A systematic review was conducted on November 12, 2021, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-analyses of Observational Studies in Epidemiology) guidelines to search for articles featuring EMA studies of BPD that reported compliance rates and included sufficient data to extract relevant design features. For studies with complete data, random-effect models were used to estimate the overall compliance rate and explore its association with design features. RESULTS In total, 28 peer-reviewed EMA studies comprising 2052 participants were included in the study. Design features (sampling strategy, average prompting frequency, number of items, response window, sampling device, financial incentive, and dropout rate) showed a large variability across studies, and many studies did not report design features. The meta-analytic synthesis was restricted to 64% (18/28) of articles and revealed a pooled compliance rate of 79% across studies. We did not find any significant relationship between design features and compliance rates. CONCLUSIONS Our results show wide variability in the design and reporting of EMA studies assessing BPD. Compliance rates appear to be stable across varying setups, and it is likely that standard design features are not directly responsible for improving or diminishing compliance. We discuss possible nonspecific factors of study design that may have an impact on compliance. Given the promise of EMA research in BPD, we also discuss the importance of unifying standards for EMA reporting so that data stemming from this rich literature can be aggregated and interpreted jointly.
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Affiliation(s)
- Antonella Davanzo
- Escuela de Psicología, Pontificia Universidad Católica de Chile, Instituto Milenio para la Investigación en Depresión y Personalidad, Santiago, Chile
| | - Delfine D Huart
- Department of Child and Adolescent Psychiatry Research, University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Süheyla Seker
- Department of Child and Adolescent Psychiatry Research, University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Markus Moessner
- University Hospital Heidelberg, Center for Psychotherapy Research, Heidelberg, Germany
| | - Ronan Zimmermann
- Department of Child and Adolescent Psychiatry Research, University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Klaus Schmeck
- Department of Child and Adolescent Psychiatry Research, University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Alex Behn
- Escuela de Psicología, Pontificia Universidad Católica de Chile, Instituto Milenio para la Investigación en Depresión y Personalidad, Santiago, Chile
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10
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Improving treatment outcomes for borderline personality disorder: what can we learn from biomarker studies of psychotherapy? Curr Opin Psychiatry 2023; 36:67-74. [PMID: 36017562 DOI: 10.1097/yco.0000000000000820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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11
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Hazlett EA, Goldstein KE, Haznedar MM, McClure MM, Perez-Rodriguez MM, New AS, Goodman M, Govindarajulu U, Kapil-Pair KN, Feinberg A, Smith E, Dolgopolskaia ES. Hyperreactivity and Impaired Habituation of Startle Amplitude During Unpleasant Pictures in Borderline but Not Schizotypal Personality Disorder: Quantifying Emotion Dysregulation. Biol Psychiatry 2022; 92:573-582. [PMID: 35717211 DOI: 10.1016/j.biopsych.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 03/23/2022] [Accepted: 04/11/2022] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Erin A Hazlett
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York; Mental Illness Research, Education and Clinical Center (VISN 2), James J. Peters Veterans Affairs Medical Center, Bronx, New York.
| | - Kim E Goldstein
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York; Mental Illness Research, Education and Clinical Center (VISN 2), James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - M Mehmet Haznedar
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York; Outpatient Psychiatry, James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Margaret M McClure
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Antonia S New
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marianne Goodman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York; Mental Illness Research, Education and Clinical Center (VISN 2), James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Usha Govindarajulu
- Center for Biostatistics, Department of Population Health & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Abigail Feinberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Emma Smith
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
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12
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Goldway N, Jalon I, Keynan JN, Hellrung L, Horstmann A, Paret C, Hendler T. Feasibility and utility of amygdala neurofeedback. Neurosci Biobehav Rev 2022; 138:104694. [PMID: 35623447 DOI: 10.1016/j.neubiorev.2022.104694] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/12/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
Amygdala NeuroFeedback (NF) have the potential of being a valuable non-invasive intervention tool in many psychiatric disporders. However, the feasibility and best practices of this method have not been systematically examined. The current article presents a review of amygdala-NF studies, an analytic summary of study design parameters, and examination of brain mechanisms related to successful amygdala-NF performance. A meta-analysis of 33 publications showed that real amygdala-NF facilitates learned modulation compared to control conditions. In addition, while variability in study dsign parameters is high, these design choices are implicitly organized by the targeted valence domain (positive or negative). However, in most cases the neuro-behavioral effects of targeting such domains were not directly assessed. Lastly, re-analyzing six data sets of amygdala-fMRI-NF revealed that successful amygdala down-modulation is coupled with deactivation of the posterior insula and nodes in the Default-Mode-Network. Our findings suggest that amygdala self-modulation can be acquired using NF. Yet, additional controlled studies, relevant behavioral tasks before and after NF intervention, and neural 'target engagement' measures are critically needed to establish efficacy and specificity. In addition, the fMRI analysis presented here suggest that common accounts regarding the brain network involved in amygdala NF might reflect unsuccessful modulation attempts rather than successful modulation.
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Affiliation(s)
- Noam Goldway
- Sagol Brain Institute, Wohl Institute for Advanced Imaging, Tel-Aviv Sourasky Medical Centre, Tel-Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel-Aviv, Israel; Department of Psychology, New York University, New York, USA
| | - Itamar Jalon
- Sagol Brain Institute, Wohl Institute for Advanced Imaging, Tel-Aviv Sourasky Medical Centre, Tel-Aviv, Israel; School of Psychological Sciences, Tel Aviv University, Tel-Aviv, Israel
| | - Jackob N Keynan
- Sagol Brain Institute, Wohl Institute for Advanced Imaging, Tel-Aviv Sourasky Medical Centre, Tel-Aviv, Israel; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, USA
| | - Lydia Hellrung
- Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Laboratory for Social and Neural Systems Research, Department of Economics, University of Zurich, Zurich, Switzerland
| | - Annette Horstmann
- Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Faculty of Medicine, University of Leipzig, Leipzig, Germany; Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Christian Paret
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, Germany
| | - Talma Hendler
- Sagol Brain Institute, Wohl Institute for Advanced Imaging, Tel-Aviv Sourasky Medical Centre, Tel-Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel-Aviv, Israel; School of Psychological Sciences, Tel Aviv University, Tel-Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel.
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13
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Steward T, Martínez-Zalacaín I, Mestre-Bach G, Sánchez I, Riesco N, Jiménez-Murcia S, Fernández-Formoso JA, Veciana de Las Heras M, Custal N, Menchón JM, Soriano-Mas C, Fernandez-Aranda F. Dorsolateral prefrontal cortex and amygdala function during cognitive reappraisal predicts weight restoration and emotion regulation impairment in anorexia nervosa. Psychol Med 2022; 52:844-852. [PMID: 32698931 DOI: 10.1017/s0033291720002457] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although deficits in affective processing are a core component of anorexia nervosa (AN), we lack a detailed characterization of the neurobiological underpinnings of emotion regulation impairment in AN. Moreover, it remains unclear whether these neural correlates scale with clinical outcomes. METHODS We investigated the neural correlates of negative emotion regulation in a sample of young women receiving day-hospital treatment for AN (n = 21) and healthy controls (n = 21). We aimed to determine whether aberrant brain activation patterns during emotion regulation predicted weight gain following treatment in AN patients and were linked to AN severity. To achieve this, participants completed a cognitive reappraisal paradigm during functional magnetic resonance imaging. Skin conductance response, as well as subjective distress ratings, were recorded to corroborate task engagement. RESULTS Compared to controls, patients with AN showed reduced activation in the dorsolateral prefrontal cortex (dlPFC) during cognitive reappraisal [pFWE<0.05, threshold-free cluster enhancement (TFCE) corrected]. Importantly, psycho-physiological interaction analysis revealed reduced functional connectivity between the dlPFC and the amygdala in AN patients during emotion regulation (pFWE<0.05, TFCE corrected), and dlPFC-amygdala uncoupling was associated with emotion regulation deficits (r = -0.511, p = 0.018) and eating disorder severity (r = -0.565, p = .008) in the AN group. Finally, dlPFC activity positively correlated with increases in body mass index (r = 0.471, p = 0.042) and in body fat mass percentage (r = 0.605, p = 0.008) following 12 weeks of treatment. CONCLUSIONS Taken together, our findings indicate that individuals with AN present altered fronto-amygdalar response during cognitive reappraisal and that this response may serve as a predictor of response to treatment and be linked to clinical severity.
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Affiliation(s)
- Trevor Steward
- Melbourne School of Psychological Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Ciber Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto Salud Carlos III, Barcelona, Spain
- Department of Psychiatry, Bellvitge University Hospital -IDIBELL, Barcelona, Spain
| | - Ignacio Martínez-Zalacaín
- Department of Psychiatry, Bellvitge University Hospital -IDIBELL, Barcelona, Spain
- Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Gemma Mestre-Bach
- Ciber Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto Salud Carlos III, Barcelona, Spain
- Department of Psychiatry, Bellvitge University Hospital -IDIBELL, Barcelona, Spain
- Facultad de Ciencias de la Salud, Universidad Internacional de La Rioja, La Rioja, Spain
| | - Isabel Sánchez
- Ciber Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto Salud Carlos III, Barcelona, Spain
- Department of Psychiatry, Bellvitge University Hospital -IDIBELL, Barcelona, Spain
| | - Nadine Riesco
- Ciber Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto Salud Carlos III, Barcelona, Spain
- Department of Psychiatry, Bellvitge University Hospital -IDIBELL, Barcelona, Spain
| | - Susana Jiménez-Murcia
- Ciber Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto Salud Carlos III, Barcelona, Spain
- Department of Psychiatry, Bellvitge University Hospital -IDIBELL, Barcelona, Spain
- Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Jose A Fernández-Formoso
- Ciber Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto Salud Carlos III, Barcelona, Spain
| | | | - Nuria Custal
- Department of Psychiatry, Bellvitge University Hospital -IDIBELL, Barcelona, Spain
| | - Jose M Menchón
- Department of Psychiatry, Bellvitge University Hospital -IDIBELL, Barcelona, Spain
- Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
- Ciber Mental Health (CIBERSAM), Instituto Salud Carlos III, Barcelona, Spain
| | - Carles Soriano-Mas
- Department of Psychiatry, Bellvitge University Hospital -IDIBELL, Barcelona, Spain
- Ciber Mental Health (CIBERSAM), Instituto Salud Carlos III, Barcelona, Spain
- Department of Psychobiology and Methodology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Fernando Fernandez-Aranda
- Ciber Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto Salud Carlos III, Barcelona, Spain
- Department of Psychiatry, Bellvitge University Hospital -IDIBELL, Barcelona, Spain
- Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
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14
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Taschereau-Dumouchel V, Cushing C, Lau H. Real-Time Functional MRI in the Treatment of Mental Health Disorders. Annu Rev Clin Psychol 2022; 18:125-154. [DOI: 10.1146/annurev-clinpsy-072220-014550] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Multiple mental disorders have been associated with dysregulation of precise brain processes. However, few therapeutic approaches can correct such specific patterns of brain activity. Since the late 1960s and early 1970s, many researchers have hoped that this feat could be achieved by closed-loop brain imaging approaches, such as neurofeedback, that aim to modulate brain activity directly. However, neurofeedback never gained mainstream acceptance in mental health, in part due to methodological considerations. In this review, we argue that, when contemporary methodological guidelines are followed, neurofeedback is one of the few intervention methods in psychology that can be assessed in double-blind placebo-controlled trials. Furthermore, using new advances in machine learning and statistics, it is now possible to target very precise patterns of brain activity for therapeutic purposes. We review the recent literature in functional magnetic resonance imaging neurofeedback and discuss current and future applications to mental health. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Vincent Taschereau-Dumouchel
- Department of Psychiatry and Addictology, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montréal, Québec, Canada
| | - Cody Cushing
- Department of Psychology, University of California, Los Angeles, California, USA
| | - Hakwan Lau
- RIKEN Center for Brain Science, Wakoshi, Saitama, Japan
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15
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Nicholson AA, Rabellino D, Densmore M, Frewen PA, Steryl D, Scharnowski F, Théberge J, Neufeld RWJ, Schmahl C, Jetly R, Lanius RA. Differential mechanisms of posterior cingulate cortex downregulation and symptom decreases in posttraumatic stress disorder and healthy individuals using real-time fMRI neurofeedback. Brain Behav 2022; 12:e2441. [PMID: 34921746 PMCID: PMC8785646 DOI: 10.1002/brb3.2441] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 10/25/2021] [Accepted: 11/09/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Intrinsic connectivity networks, including the default mode network (DMN), are frequently disrupted in individuals with posttraumatic stress disorder (PTSD). The posterior cingulate cortex (PCC) is the main hub of the posterior DMN, where the therapeutic regulation of this region with real-time fMRI neurofeedback (NFB) has yet to be explored. METHODS We investigated PCC downregulation while processing trauma/stressful words over 3 NFB training runs and a transfer run without NFB (total n = 29, PTSD n = 14, healthy controls n = 15). We also examined the predictive accuracy of machine learning models in classifying PTSD versus healthy controls during NFB training. RESULTS Both the PTSD and healthy control groups demonstrated reduced reliving symptoms in response to trauma/stressful stimuli, where the PTSD group additionally showed reduced symptoms of distress. We found that both groups were able to downregulate the PCC with similar success over NFB training and in the transfer run, although downregulation was associated with unique within-group decreases in activation within the bilateral dmPFC, bilateral postcentral gyrus, right amygdala/hippocampus, cingulate cortex, and bilateral temporal pole/gyri. By contrast, downregulation was associated with increased activation in the right dlPFC among healthy controls as compared to PTSD. During PCC downregulation, right dlPFC activation was negatively correlated to PTSD symptom severity scores and difficulties in emotion regulation. Finally, machine learning algorithms were able to classify PTSD versus healthy participants based on brain activation during NFB training with 80% accuracy. CONCLUSIONS This is the first study to investigate PCC downregulation with real-time fMRI NFB in both PTSD and healthy controls. Our results reveal acute decreases in symptoms over training and provide converging evidence for EEG-NFB targeting brain networks linked to the PCC.
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Affiliation(s)
- Andrew A Nicholson
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada.,Department of Cognition, Emotion, and Methods in Psychology, University of Vienna, Vienna, Austria
| | - Daniela Rabellino
- Department of Neuroscience, Western University, London, Ontario, Canada.,Imaging, Lawson Health Research Institute, London, Ontario, Canada
| | - Maria Densmore
- Imaging, Lawson Health Research Institute, London, Ontario, Canada.,Department of Psychiatry, Western University, London, Ontario, Canada
| | - Paul A Frewen
- Department of Neuroscience, Western University, London, Ontario, Canada.,Department of Psychology, Western University, London, Ontario, Canada
| | - David Steryl
- Department of Cognition, Emotion, and Methods in Psychology, University of Vienna, Vienna, Austria
| | - Frank Scharnowski
- Department of Cognition, Emotion, and Methods in Psychology, University of Vienna, Vienna, Austria
| | - Jean Théberge
- Imaging, Lawson Health Research Institute, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada.,Department of Psychiatry, Western University, London, Ontario, Canada.,Department of Diagnostic Imaging, St. Joseph's Healthcare, London, Ontario, Canada
| | - Richard W J Neufeld
- Department of Neuroscience, Western University, London, Ontario, Canada.,Department of Psychology, Western University, London, Ontario, Canada.,Department of Psychiatry, Western University, London, Ontario, Canada.,Department of Psychology, University of British Columbia, Okanagan, Kelowna, British Columbia, Canada
| | - Christian Schmahl
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Heidelberg University, Heidelberg, Germany
| | - Rakesh Jetly
- Canadian Forces, Health Services, Ottawa, Ontario, Canada
| | - Ruth A Lanius
- Department of Neuroscience, Western University, London, Ontario, Canada.,Imaging, Lawson Health Research Institute, London, Ontario, Canada.,Department of Psychiatry, Western University, London, Ontario, Canada
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16
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Neukel C, Bertsch K, Wenigmann M, Spieß K, Krauch M, Steinmann S, Herpertz SC. A Mechanism-Based Approach to Anti-Aggression Psychotherapy in Borderline Personality Disorder: Group Treatment Affects Amygdala Activation and Connectivity. Brain Sci 2021; 11:brainsci11121627. [PMID: 34942929 PMCID: PMC8699721 DOI: 10.3390/brainsci11121627] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/30/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Corinne Neukel
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, 69115 Heidelberg, Germany; (K.B.); (M.W.); (K.S.); (M.K.); (S.C.H.)
- Correspondence:
| | - Katja Bertsch
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, 69115 Heidelberg, Germany; (K.B.); (M.W.); (K.S.); (M.K.); (S.C.H.)
- Department of Psychology, Ludwig-Maximilians-University Munich, 80802 Munich, Germany
| | - Marc Wenigmann
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, 69115 Heidelberg, Germany; (K.B.); (M.W.); (K.S.); (M.K.); (S.C.H.)
| | - Karen Spieß
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, 69115 Heidelberg, Germany; (K.B.); (M.W.); (K.S.); (M.K.); (S.C.H.)
| | - Marlene Krauch
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, 69115 Heidelberg, Germany; (K.B.); (M.W.); (K.S.); (M.K.); (S.C.H.)
- Institute of Medical Psychology, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, 69115 Heidelberg, Germany
| | - Sylvia Steinmann
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, 68159 Mannheim, Germany;
| | - Sabine C. Herpertz
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, 69115 Heidelberg, Germany; (K.B.); (M.W.); (K.S.); (M.K.); (S.C.H.)
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17
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Zweerings J, Sarasjärvi K, Mathiak KA, Iglesias-Fuster J, Cong F, Zvyagintsev M, Mathiak K. Data-Driven Approach to the Analysis of Real-Time FMRI Neurofeedback Data: Disorder-Specific Brain Synchrony in PTSD. Int J Neural Syst 2021; 31:2150043. [PMID: 34551675 DOI: 10.1142/s012906572150043x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Brain-computer interfaces (BCIs) can be used in real-time fMRI neurofeedback (rtfMRI NF) investigations to provide feedback on brain activity to enable voluntary regulation of the blood-oxygen-level dependent (BOLD) signal from localized brain regions. However, the temporal pattern of successful self-regulation is dynamic and complex. In particular, the general linear model (GLM) assumes fixed temporal model functions and misses other dynamics. We propose a novel data-driven analyses approach for rtfMRI NF using intersubject covariance (ISC) analysis. The potential of ISC was examined in a reanalysis of data from 21 healthy individuals and nine patients with post-traumatic stress-disorder (PTSD) performing up-regulation of the anterior cingulate cortex (ACC). ISC in the PTSD group differed from healthy controls in a network including the right inferior frontal gyrus (IFG). In both cohorts, ISC decreased throughout the experiment indicating the development of individual regulation strategies. ISC analyses are a promising approach to reveal novel information on the mechanisms involved in voluntary self-regulation of brain signals and thus extend the results from GLM-based methods. ISC enables a novel set of research questions that can guide future neurofeedback and neuroimaging investigations.
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Affiliation(s)
- Jana Zweerings
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen Germany.,JARA-Brain, Research Center Jülich, Jülich, Germany
| | - Kiira Sarasjärvi
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen Germany.,Department of Digital Humanities, University of Helsinki, Helsinki, Finland
| | - Krystyna Anna Mathiak
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen Germany.,JARA-Brain, Research Center Jülich, Jülich, Germany
| | | | - Fengyu Cong
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, 116024 Dalian, P. R. China.,Faculty of Information Technology, University of Jyväskylä, 40014 Jyväskylä, Finland.,School of Artificial Intelligence, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, 116024 Dalian, P. R. China.,Key Laboratory of Integrated Circuit and Biomedical Electronic System, Liaoning Province, Dalian University of Technology, 116024 Dalian, P. R. China
| | - Mikhail Zvyagintsev
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen Germany.,JARA-Brain, Research Center Jülich, Jülich, Germany
| | - Klaus Mathiak
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen Germany.,JARA-Brain, Research Center Jülich, Jülich, Germany
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18
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Zarnowski O, Ziton S, Holmberg R, Musto S, Riegle S, Van Antwerp E, Santos-Nunez G. Functional MRI findings in personality disorders: A review. J Neuroimaging 2021; 31:1049-1066. [PMID: 34468063 DOI: 10.1111/jon.12924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Oskar Zarnowski
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Shirley Ziton
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Rylan Holmberg
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Sarafina Musto
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Sean Riegle
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Emily Van Antwerp
- West Virginia School of Osteopathic Medicine, Lewisburg, West Virginia, USA
| | - Gabriela Santos-Nunez
- University of Massachusetts Memorial Medical Center, Radiology Department, Worcester, Massachusetts, USA
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19
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Paul P, Bennett CN. Review of Neuropsychological and Electrophysiological Correlates of Callous-unemotional Traits in Children: Implications for EEG Neurofeedback Intervention. Clin EEG Neurosci 2021; 52:321-329. [PMID: 33709806 DOI: 10.1177/1550059421997129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Conduct disorder is a significant psychiatric disorder of childhood and adolescence. The Diagnostic and Statistical Manual of Mental Disorders, fifth version (DSM-5), added the limited prosocial specifier to identify those individuals who exhibit a more severe pattern of behavior characterized by a callous and unemotional (CU) interpersonal style across multiple settings and relationships. This review has attempted to summarize the relevant research focusing on the significance of CU interpersonal style in the development of psychopathy. The primary focus was on the electrophysiological and neuropsychological correlates of CU traits and their implication on the treatment protocol using neurofeedback training for children with such traits. The source of the literature search was PubMed, which majorly uses the MEDLINE database. The keywords used included CU traits, conduct disorder, child psychopathy, empathy, electrophysiology, criminal behavior, neuropsychology, neurofeedback training, and so on. Studies from the last 15 years were considered for the review. This review revealed that children with conduct disorder and high-CU traits with a combination of reactive and proactive aggression are more likely to develop psychopathy. Evidence suggests that these children have distinct forms of electrophysiological and neuropsychological correlates. However, research in this area is still not conclusive as they yield variation in findings. Studies on the efficacy of neurofeedback training on reducing symptoms such as impulsivity, hostility, and psychopathy indicate that neurofeedback training can be a promising treatment alternative for children with severe conduct disorder.
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20
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Degasperi G, Cristea IA, Di Rosa E, Costa C, Gentili C. Parsing variability in borderline personality disorder: a meta-analysis of neuroimaging studies. Transl Psychiatry 2021; 11:314. [PMID: 34031363 PMCID: PMC8144551 DOI: 10.1038/s41398-021-01446-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/01/2021] [Accepted: 05/14/2021] [Indexed: 02/04/2023] Open
Abstract
Though a plethora of functional magnetic resonance imaging (fMRI) studies explored the neurobiological underpinnings of borderline personality disorder (BPD), findings across different tasks were divergent. We conducted a systematic review and activation likelihood estimation (ALE) meta-analysis on the fMRI studies conducted in BPD patients compared to healthy controls (HC). We systematically searched PubMed and PsychINFO from inception until July 9th 2020 using combinations of database-specific terms like 'fMRI', 'Neuroimaging', 'borderline'. Eligible studies employed task-based fMRI of the brain in participants of any age diagnosed with BPD compared to HC, during any behavioral task and providing a direct contrast between the groups. From 762 entries, we inspected 92 reports full-texts and included 52 studies (describing 54 experiments). Across all experiments, the HC > BPD and BPD > HC meta-analyses did not yield any cluster of significant convergence of differences. Analyses restricted to studies of emotion processing revealed two significant clusters of activation in the bilateral hippocampal/amygdala complex and anterior cingulate for the BPD > HC meta-analysis. Fail-safe N and single study sensitivity analysis suggested significant findings were not robust. For the subgroup of emotional processing experiments, on a restricted number of experiments providing results for each group separately, another meta-analysis method (difference of convergence) showed a significant cluster in the insula/inferior frontal gyrus for the HC > BPD contrast. No consistent pattern of alteration in brain activity for BPD was evidenced suggesting substantial heterogeneity of processes and populations studied. A pattern of amygdala dysfunction emerged across emotion processing tasks, indicating a potential pathophysiological mechanism that could be transdiagnostic.
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Affiliation(s)
- Giorgia Degasperi
- Department of General Psychology, University of Padova, Padova, Italy
| | - Ioana Alina Cristea
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- IRCCS Mondino Foundation, Pavia, Italy
| | - Elisa Di Rosa
- Department of General Psychology, University of Padova, Padova, Italy
| | - Cristiano Costa
- Department of General Psychology, University of Padova, Padova, Italy
| | - Claudio Gentili
- Department of General Psychology, University of Padova, Padova, Italy.
- Padova Neuroscience Center, University of Padova, Padova, Italy.
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21
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Krause-Utz A, Frost R, Chatzaki E, Winter D, Schmahl C, Elzinga BM. Dissociation in Borderline Personality Disorder: Recent Experimental, Neurobiological Studies, and Implications for Future Research and Treatment. Curr Psychiatry Rep 2021; 23:37. [PMID: 33909198 PMCID: PMC8081699 DOI: 10.1007/s11920-021-01246-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Annegret Krause-Utz
- Institute of Clinical Psychology, Leiden University, Leiden, The Netherlands.
- Leiden Institute for Brain and Cognition (LIBC), Leiden, The Netherlands.
| | - Rachel Frost
- Department of Psychology, King's College London, Institute of Psychiatry Psychology & Neuroscience, London, UK
| | - Elianne Chatzaki
- Institute of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - Dorina Winter
- Pain and Psychotherapy Research Lab, University of Koblenz-Landau, Landau, Germany
| | - Christian Schmahl
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Bernet M Elzinga
- Institute of Clinical Psychology, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition (LIBC), Leiden, The Netherlands
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22
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Sicorello M, Schmahl C. Emotion dysregulation in borderline personality disorder: A fronto–limbic imbalance? Curr Opin Psychol 2021; 37:114-120. [DOI: 10.1016/j.copsyc.2020.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/18/2020] [Accepted: 12/07/2020] [Indexed: 12/30/2022]
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23
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Seitz KI, Leitenstorfer J, Krauch M, Hillmann K, Boll S, Ueltzhoeffer K, Neukel C, Kleindienst N, Herpertz SC, Bertsch K. An eye-tracking study of interpersonal threat sensitivity and adverse childhood experiences in borderline personality disorder. Borderline Personal Disord Emot Dysregul 2021; 8:2. [PMID: 33397512 PMCID: PMC7784013 DOI: 10.1186/s40479-020-00141-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/25/2020] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Katja I Seitz
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany.
| | - Johanna Leitenstorfer
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Marlene Krauch
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Karen Hillmann
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Sabrina Boll
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Kai Ueltzhoeffer
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Corinne Neukel
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Nikolaus Kleindienst
- Institute for Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sabine C Herpertz
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Katja Bertsch
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany
- Department of Psychology, Ludwig-Maximilians-University Munich, Munich, Germany
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24
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Iskric A, Barkley-Levenson E. Neural Changes in Borderline Personality Disorder After Dialectical Behavior Therapy-A Review. Front Psychiatry 2021; 12:772081. [PMID: 34975574 PMCID: PMC8718753 DOI: 10.3389/fpsyt.2021.772081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Adam Iskric
- Department of Psychology, Hofstra University, Hempstead, NY, United States
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25
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Paulus FW, Ohmann S, Möhler E, Plener P, Popow C. Emotional Dysregulation in Children and Adolescents With Psychiatric Disorders. A Narrative Review. Front Psychiatry 2021; 12:628252. [PMID: 34759846 PMCID: PMC8573252 DOI: 10.3389/fpsyt.2021.628252] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 08/27/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Emotional dysregulation (ED) is a transdiagnostic construct defined as the inability to regulate the intensity and quality of emotions (such as, fear, anger, sadness), in order to generate an appropriate emotional response, to handle excitability, mood instability, and emotional overreactivity, and to come down to an emotional baseline. Because ED has not been defined as a clinical entity, and because ED plays a major role in child and adolescent psychopathology, we decided to summarize current knowledge on this topic based on a narrative review of the current literature. Methods: This narrative review is based on a literature search of peer-reviewed journals. We searched the databases ERIC, PsycARTICLES, PsycINFO and PSYNDEX on June 2, 2020 for peer reviewed articles published between 2000 and 2020 in English language for the preschool, school, and adolescent age (2-17 years) using the following search terms: "emotional dysregulation" OR "affect dysregulation," retrieving 943 articles. Results: The results of the literature search are presented in the following sections: the relationship between ED and psychiatric disorders (ADHD, Mood Disorders, Psychological Trauma, Posttraumatic Stress Disorder, Non-suicidal Self-Injury, Eating Disorders, Oppositional Defiant Disorder, Conduct Disorder, Disruptive Disruptive Mood Dysregulation Disorder, Personality Disorders, Substance Use Disorder, Developmental Disorders, Autism Spectrum Disorder, Psychosis and Schizophrenia, and Gaming Disorder), prevention, and treatment of ED. Conclusion: Basic conditions of ED are genetic disposition, the experience of trauma, especially sexual or physical abuse, emotional neglect in childhood or adolescence, and personal stress. ED is a complex construct and a comprehensive concept, aggravating a number of various mental disorders. Differential treatment is mandatory for individual and social functioning.
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Affiliation(s)
- Frank W Paulus
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Saarland University Medical Center, Homburg, Germany
| | - Susanne Ohmann
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria.,Austrian Society of Cognitive Behavioral Therapy (OeGVT), Vienna, Austria
| | - Eva Möhler
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Saarland University Medical Center, Homburg, Germany
| | - Paul Plener
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Christian Popow
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria.,Austrian Society of Cognitive Behavioral Therapy (OeGVT), Vienna, Austria.,Department of Child and Adolescent Psychiatry and Psychotherapy, Regional Psychiatric Hospital, Mauer, Austria
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26
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Tursic A, Eck J, Lührs M, Linden DEJ, Goebel R. A systematic review of fMRI neurofeedback reporting and effects in clinical populations. Neuroimage Clin 2020; 28:102496. [PMID: 33395987 PMCID: PMC7724376 DOI: 10.1016/j.nicl.2020.102496] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/22/2022]
Abstract
Real-time fMRI-based neurofeedback is a relatively young field with a potential to impact the currently available treatments of various disorders. In order to evaluate the evidence of clinical benefits and investigate how consistently studies report their methods and results, an exhaustive search of fMRI neurofeedback studies in clinical populations was performed. Reporting was evaluated using a limited number of Consensus on the reporting and experimental design of clinical and cognitive-behavioral neurofeedback studies (CRED-NF checklist) items, which was, together with a statistical power and sensitivity calculation, used to also evaluate the existing evidence of the neurofeedback benefits on clinical measures. The 62 found studies investigated regulation abilities and/or clinical benefits in a wide range of disorders, but with small sample sizes and were therefore unable to detect small effects. Most points from the CRED-NF checklist were adequately reported by the majority of the studies, but some improvements are suggested for the reporting of group comparisons and relations between regulation success and clinical benefits. To establish fMRI neurofeedback as a clinical tool, more emphasis should be placed in the future on using larger sample sizes determined through a priori power calculations and standardization of procedures and reporting.
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Affiliation(s)
- Anita Tursic
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Oxfordlaan 55, 6229 EV Maastricht, The Netherlands; Brain Innovation B.V, Oxfordlaan 55, 6229 EV Maastricht, The Netherlands.
| | - Judith Eck
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Oxfordlaan 55, 6229 EV Maastricht, The Netherlands; Brain Innovation B.V, Oxfordlaan 55, 6229 EV Maastricht, The Netherlands.
| | - Michael Lührs
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Oxfordlaan 55, 6229 EV Maastricht, The Netherlands; Brain Innovation B.V, Oxfordlaan 55, 6229 EV Maastricht, The Netherlands.
| | - David E J Linden
- School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands.
| | - Rainer Goebel
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Oxfordlaan 55, 6229 EV Maastricht, The Netherlands; Brain Innovation B.V, Oxfordlaan 55, 6229 EV Maastricht, The Netherlands; Department of Neuroimaging and Neuromodeling, Netherlands Institute for Neuroscience, Meibergdreef 47, 1105 BA Amsterdam, the Netherlands.
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27
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Muñoz-Moldes S, Cleeremans A. Delineating implicit and explicit processes in neurofeedback learning. Neurosci Biobehav Rev 2020; 118:681-688. [PMID: 32918947 PMCID: PMC7758707 DOI: 10.1016/j.neubiorev.2020.09.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/09/2020] [Accepted: 09/05/2020] [Indexed: 11/21/2022]
Abstract
Neurofeedback allows humans to self-regulate neural activity in specific brain regions and is considered a promising tool for psychiatric interventions. Recently, methods have been developed to use neurofeedback implicitly, prompting a theoretical debate on the role of awareness in neurofeedback learning. We offer a critical review of the role of awareness in neurofeedback learning, with a special focus on recently developed neurofeedback paradigms. We detail differences in instructions and propose a fine-grained categorization of tasks based on the degree of involvement of explicit and implicit processes. Finally, we review the methods used to measure awareness in neurofeedback and propose new candidate measures. We conclude that explicit processes cannot be eschewed in most current implicit tasks that have explicit goals, and suggest ways in which awareness could be better measured in the future. Investigating awareness during learning will help understand the learning mechanisms underlying neurofeedback learning and will help shape future tasks.
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Affiliation(s)
- Santiago Muñoz-Moldes
- Consciousness, Cognition and Computation group, Center for Research in Cognition & Neuroscience, Faculty of Psychology and Education, Université Libre de Bruxelles, 1050 Brussels, Belgium; Department of Psychology, University of Cambridge, Cambridge, United Kingdom.
| | - Axel Cleeremans
- Consciousness, Cognition and Computation group, Center for Research in Cognition & Neuroscience, Faculty of Psychology and Education, Université Libre de Bruxelles, 1050 Brussels, Belgium.
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28
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Zweerings J, Sarkheil P, Keller M, Dyck M, Klasen M, Becker B, Gaebler AJ, Ibrahim CN, Turetsky BI, Zvyagintsev M, Flatten G, Mathiak K. Rt-fMRI neurofeedback-guided cognitive reappraisal training modulates amygdala responsivity in posttraumatic stress disorder. NEUROIMAGE-CLINICAL 2020; 28:102483. [PMID: 33395974 PMCID: PMC7689411 DOI: 10.1016/j.nicl.2020.102483] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 10/15/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022]
Abstract
We found neurofeedback-specific attenuation of amygdala responses. Trauma symptoms and the affective state improved in patients at one-month follow-up. Reduced amygdala responses were associated with improved well-being at follow-up. 75% of individuals with PTSD used the learned strategies in daily life. Left lateral prefrontal cortex responses were reduced during neurofeedback training.
Background Traumatic experiences are associated with neurofunctional dysregulations in key regions of the emotion regulation circuits. In particular, amygdala responsivity to negative stimuli is exaggerated while engagement of prefrontal regulatory control regions is attenuated. Successful application of emotion regulation (ER) strategies may counteract this disbalance, however, application of learned strategies in daily life is hampered in individuals afflicted by posttraumatic stress disorder (PTSD). We hypothesized that a single session of real-time fMRI (rtfMRI) guided upregulation of prefrontal regions during an emotion regulation task enhances self-control during exposure to negative stimuli and facilitates transfer of the learned ER skills to daily life. Methods In a cross-over design, individuals with a PTSD diagnosis after a single traumatic event (n = 20) according to DSM-IV-TR criteria and individuals without a formal psychiatric diagnosis (n = 21) underwent a cognitive reappraisal training. In randomized order, all participants completed two rtfMRI neurofeedback (NF) runs targeting the left lateral prefrontal cortex (lPFC) and two control runs without NF (NoNF) while using cognitive reappraisal to reduce their emotional response to negative scenes. During the NoNF runs, two %%-signs were displayed instead of the two-digit feedback (FB) to achieve a comparable visual stimulation. The project aimed at defining the clinical potential of the training according to three success markers: (1) NF induced changes in left lateral prefrontal cortex and bilateral amygdala activity during the regulation of aversive scenes compared to cognitive reappraisal alone (primary registered outcome), (2) associated changes on the symptomatic and behavioral level such as indicated by PTSD symptom severity and affect ratings, (3) clinical utility such as indicated by perceived efficacy, acceptance, and transfer to daily life measured four weeks after the training. Results In comparison to the reappraisal without feedback, a neurofeedback-specific decrease in the left lateral PFC (d = 0.54) alongside an attenuation of amygdala responses (d = 0.33) emerged. Reduced amygdala responses during NF were associated with symptom improvement (r = −0.42) and less negative affect (r = −0.63) at follow-up. The difference in symptom scores exceeds requirements for a minimal clinically important difference and corresponds to a medium effect size (d = 0.64). Importantly, 75% of individuals with PTSD used the strategies in daily life during a one-month follow-up period and perceived the training as efficient. Conclusion Our findings suggest beneficial effects of the NF training indicated by reduced amygdala responses that were associated with improved symptom severity and affective state four weeks after the NF training as well as patient-centered perceived control during the training, helpfulness and application of strategies in daily life. However, reduced prefrontal involvement was unexpected. The study suggests good tolerability of the training protocol and potential for clinical use in the treatment of PTSD.
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Affiliation(s)
- Jana Zweerings
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen, Germany; Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich, Germany.
| | - Pegah Sarkheil
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen, Germany; Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich, Germany
| | - Micha Keller
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen, Germany; Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich, Germany
| | - Miriam Dyck
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen, Germany; Novarea RPK, Aachen, Germany
| | - Martin Klasen
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen, Germany; Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich, Germany
| | - Benjamin Becker
- The Clinical Hospital of the Chengdu Brain Science Institute, School of Life Science and Technology, Key Laboratory for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
| | - Arnim J Gaebler
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen, Germany; Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich, Germany
| | - Camellia N Ibrahim
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen, Germany; Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich, Germany
| | - Bruce I Turetsky
- Neuropsychiatry Section, Department of Psychiatry, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Mikhail Zvyagintsev
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen, Germany; Brain Imaging Facility, Interdisciplinary Centre for Clinical Studies (IZKF), School of Medicine, RWTH Aachen University, Germany
| | - Guido Flatten
- Euregio-Institut für Psychosomatik und Psychotraumatologie, Aachen, Germany
| | - Klaus Mathiak
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Aachen, Germany; Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich, Germany
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29
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Dhaliwal K, Danzig A, Fineberg SK. Improving Research Practice for Studying Borderline Personality Disorder: Lessons From the Clinic. ACTA ACUST UNITED AC 2020; 4:2470547020912504. [PMID: 32518886 PMCID: PMC7254581 DOI: 10.1177/2470547020912504] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/23/2020] [Indexed: 12/25/2022]
Abstract
Borderline personality disorder is an often misunderstood and underdiagnosed mental illness characterized in part by affective lability. Clinicians’ unique understanding of the disorder has allowed them to develop disorder-specific approaches to treatment. In this review, we highlight how borderline personality disorder research can benefit from greater engagement with key disorder-specific features, including symptom variability and interpersonal sensitivity. In addition, we propose that research which employs interactive tasks will be more reflective of the kinds of volatility found in the real-life situations. Finally, we discuss how mixed-methodology can serve as a way for recovery-oriented research to practice the very ideals and recommendations it suggests. We use a patient case to contextualize each section. As interest in borderline personality disorder continues to grow, an intentional emphasis on a person-centered, recovery-focused, and disorder-specific approach to research is needed.
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Affiliation(s)
- Khushwant Dhaliwal
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Ayala Danzig
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Sarah K Fineberg
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
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30
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Frías Á, Solves L, Navarro S, Palma C, Farriols N, Aliaga F, Hernández M, Antón M, Riera A. Technology-Based Psychosocial Interventions for People with Borderline Personality Disorder: A Scoping Review of the Literature. Psychopathology 2020; 53:254-263. [PMID: 33166964 DOI: 10.1159/000511349] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/02/2020] [Indexed: 11/19/2022]
Abstract
Evidence-based psychosocial interventions for borderline personality disorder (BPD) still face multiple challenges regarding treatment accessibility, adherence, duration, and economic costs. Over the last decade, technology has addressed these concerns from different disciplines. The current scoping review aimed to delineate novel and ongoing clinical research on technology-based psychosocial interventions for patients with BPD. Online databases (PubMed, Cochrane Library, EMBASE, Web of Science, PsycInfo, and Google Scholar) were searched up to June 2020. Technology-based psychosocial treatments included innovative communication (eHealth) and computational (e.g., artificial intelligence), computing (e.g., computer-based), or medical (e.g., functional magnetic resonance imaging [fMRI]) software. Clinical research encompassed any testing stage (e.g., feasibility, efficacy). Fifteen studies met the inclusion criteria. The main findings were the following: almost two-thirds of the studies (9/15) tested software explicitly conceived as adjunctive interventions to conventional therapy; nearly half of the studies (7/15) were referred to as dialectical behavior therapy-based software; most studies (13/15) were focused on the initial stage of the clinical research cycle (feasibility/acceptance/usability testing), reporting good results at this point; more than one-third of the studies (6/15) tested mobile apps; there is emerging evidence for Internet-based interventions and real-time fMRI biofeedback but only little evidence for mHealth interventions, virtual and augmented reality, and computer-based interventions; there was no computational technology-based clinical research; and there was no satisfaction/preference, security/safety, or efficiency testing for any software. Taken together, the results suggest that there is a growing but still incipient amount of technology-based psychosocial interventions for BPD supported by some kind of clinical evidence. The limitations and directions for future research are discussed.
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Affiliation(s)
- Álvaro Frías
- Facultat de Psicologia, Ciències de l'Educació i de l'Esport Blanquerna, University of Ramon-Llull, Barcelona, Spain, .,Adult Outpatient Mental Health Center, Consorci Sanitari del Maresme, Hospital of Mataró, Mataró, Spain,
| | - Laia Solves
- Facultat de Psicologia, Ciències de l'Educació i de l'Esport Blanquerna, University of Ramon-Llull, Barcelona, Spain.,Adult Outpatient Mental Health Center, Consorci Sanitari del Maresme, Hospital of Mataró, Mataró, Spain
| | - Sara Navarro
- Facultat de Psicologia, Ciències de l'Educació i de l'Esport Blanquerna, University of Ramon-Llull, Barcelona, Spain.,Adult Outpatient Mental Health Center, Consorci Sanitari del Maresme, Hospital of Mataró, Mataró, Spain
| | - Carol Palma
- Facultat de Psicologia, Ciències de l'Educació i de l'Esport Blanquerna, University of Ramon-Llull, Barcelona, Spain.,Adult Outpatient Mental Health Center, Consorci Sanitari del Maresme, Hospital of Mataró, Mataró, Spain
| | - Núria Farriols
- Facultat de Psicologia, Ciències de l'Educació i de l'Esport Blanquerna, University of Ramon-Llull, Barcelona, Spain.,Adult Outpatient Mental Health Center, Consorci Sanitari del Maresme, Hospital of Mataró, Mataró, Spain
| | - Ferrán Aliaga
- Facultat de Psicologia, Ciències de l'Educació i de l'Esport Blanquerna, University of Ramon-Llull, Barcelona, Spain.,Adult Outpatient Mental Health Center, Consorci Sanitari del Maresme, Hospital of Mataró, Mataró, Spain
| | - Mònica Hernández
- Adult Outpatient Mental Health Center, Consorci Sanitari del Maresme, Hospital of Mataró, Mataró, Spain
| | - Meritxell Antón
- Adult Outpatient Mental Health Center, Consorci Sanitari del Maresme, Hospital of Mataró, Mataró, Spain
| | - Aloma Riera
- Adult Outpatient Mental Health Center, Consorci Sanitari del Maresme, Hospital of Mataró, Mataró, Spain
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