The Neurobiology of Borderline Personality Disorder

Depression with comorbid borderline personality disorder - could ketamine be a treatment catalyst?

Borderline personality disorder (BPD) is diagnosed in 10-30% of patients with major depressive disorder (MDD), and the frequency of MDD among individuals with BPD reaches over 80%. The comorbidity of MDD and BPD is associated with more severe depressive symptoms and functional impairment, higher risk of treatment resistance and increased suicidality. The effectiveness of ketamine usage in treatment resistant depression (TRD) has been demonstrated in numerous studies. In most of these studies, individuals with BPD were not excluded, thus given the high co-occurrence of these disorders, it is possible that the beneficial effects of ketamine also extend to the subpopulation with comorbid TRD and BPD. However, no protocols were developed that would account for comorbidity. Moreover, psychotherapeutic interventions, which may be crucial for achieving a lasting therapeutic effect in TRD and BPD comorbidity, were not included. In the article, we discuss the results of a small number of existing studies and case reports on the use of ketamine in depressive disorders with comorbid BPD. We elucidate how, at the molecular and brain network levels, ketamine can impact the neurobiology and symptoms of BPD. Furthermore, we explore whether ketamine-induced neuroplasticity, augmented by psychotherapy, could be of use in alleviating core BPD-related symptoms such as emotional dysregulation, self-identity disturbances and self-harming behaviors. We also discuss the potential of ketamine-assisted psychotherapy (KAP) in BPD treatment. As there is no standard approach to the application of ketamine or KAP in individuals with comorbid TRD and BPD, we consider further research in the field as imperative. The priorities should include development of dedicated protocols, distinguishing subpopulations that may benefit most from such treatment and investigating factors that may influence its effectiveness and safety.

Assessing family relations in borderline personality disorder: A relational approach

The aims of the current study are to describe the basic family relationships, parental bonding patterns, and dyadic adjustment of families with offspring diagnosed with borderline personality disorder (BPD) and to explore the correlations between these variables related to family relations and BPD symptomatology. The sample consisted of 194 participants, including parents from the control (N = 76) and clinical group (N = 76), and patients with BPD (N = 42). All progenitors completed a measure of family relations, parental bonding, and dyadic adjustment. Patients completed a measure of parental bonding and borderline symptomatology. The results showed significant differences between both groups in marital and parental functioning, marital satisfaction, dyadic adjustment, and care. Correlations among family variables and BPD symptomatology were also found. In summary, findings underscore the significance of comprehending the complexity of family relationships in BPD while advocating for a relational perspective when examining the family dynamics.

Prevalence of personality disorders in adults with binge eating disorder-A systematic review and Bayesian meta-analysis

Binge eating disorder (BED) is a complex mental health problem entailing high risk for obesity, overweight, and other psychiatric disorders. However, there is still unclear evidence of the prevalence of personality disorders (PDs) in BED patients. We conducted a systematic review and a Bayesian meta-analysis for studies examining the prevalence of any PD in adult BED patients. Data sources included PubMed, Cochrane library, EBSCO, PsycINFO, and Science Direct. A Bayesian meta-analysis was conducted to estimate effect sizes for the prevalence of any PD in BED patients. Twenty eligible articles were examined with a total of 2945 BED patients. Borderline personality disorder and "Cluster C" PD, particularly obsessive-compulsive and avoidant PD, were the most frequent PD found in BED patients. BED diagnosis was associated with 28% probability of a comorbid diagnosis of any PD (0.279, 95%CrI: [0.22, 0.34]), with high levels of between-study heterogeneity (τ = 0.61, 95% CrI [0.40, 0.90]). Sensitivity analysis suggested effect sizes ranging from 0.27 to 0.28. The high comorbidity of PDs in BED patients draws attention to the potential complexity of BED clinical presentations, including those that might also be comorbid with obesity. Clinical practice should address this complexity to improve care for BED and obesity patients.

Intranasal oxytocin as an adjunct treatment among patients with severe major depression with and without comorbid borderline personality disorder

INTRODUCTION

Results of studies concerning a possible beneficial effect of Intranasal-Oxytocin (IN-OT) as an add-on treatment for patients with major depression (MDD) have been inconsistent. One possible explanation to account for the difference in the effect of IN-OT is comorbid borderline personality disorder (BPD). This randomized controlled study was aimed to explore the differential effect of IN-OT administration among depressive patients with or without comorbid borderline personality disorder.

METHODS

A secondary analysis was conducted on a specific subset of patients who participated in an RCT evaluating the impact of IN-OT as add-on treatment for patients with severe mental illness. Patients treated in inpatient settings (N = 58) were randomized and double-blindly allocated to receive twice daily IN-OT (32 IU) or placebo for a period of four weeks. The effect of IN-OT on therapy process and outcome was examined among patients with (n = 35) and without (n = 23) comorbid BPD.

RESULTS

An interaction effect between diagnosis and group was observed on the Outcome Questionnaire-45 (B = 8.93, p = .007). Further analysis revealed that patients without BPD demonstrated significantly greater improvements following OT administration (B = -8.32, p = .001), whereas patients with BPD did not show significant improvement (B = 0.61, p = .76). The interactive pattern was also observed in the Hopkins Symptom Checklist (B = 0.25, p = .02), where patients without BPD demonstrated significantly larger improvements following OT administration (B = -0.29, p = .0009) as compared to placebo, while patients with BPD demonstrated no significant improvement (B = -0.04, p = .55). We did not find a harmful effect of IN-OT administration among patients with MDD and comorbid BPD.

CONCLUSIONS

Patients with MDD and comorbid BPD benefit less from IN-OT administration as compared to depressed patients without BPD. Future studies should aim to identify patients who are more likely to benefit from IN-OT administration.

Components of event-related potentials and borderline personality disorder: a meta-analysis

Background: Borderline personality disorder (BPD) is characterized by symptoms associated with difficulties in emotion regulation, altered self-image, impulsivity, and instability in personal relationships. A relationship has been found between BPD symptoms and altered neuropsychological processes. Studies of event-related potentials (ERP) measured with electroencephalogram (EEG) have found neural correlates related to BPD symptoms. Of note is the P300 component, considered a potential mental health biomarker for trauma-associated disorders. However, no meta-analysis has been found to demonstrate this relationship.Objectives: To evaluate the relationship between the P300 component and BPD symptoms. To evaluate the relationship of other ERP components with BPD symptoms.Methods: The method and procedure were adjusted to the PRISMA checklist. The search was performed in three databases: WOS, Scopus and PubMed. A Random Effects Model was used to perform the analysis of the studies. In addition, a meta-regression was performed with % women, Gini and GDP. Finally, a descriptive analysis of the main results found between P300, other ERP components (LPP, P100 and ERN/Ne) and BPD symptoms was performed.Results: From a review of 485 articles, a meta-analysis was performed with six articles that met the inclusion criteria. A moderate, positive relationship was found between the P300 component and BPD symptoms (REM = .489; p < .001). It was not possible to perform meta-analyses for other ERP components (LPP, P100 and ERN/Ne) due to the low number of articles found.Conclusion: The idea that P300 could be considered for use as a biomarker to identify altered neural correlates in BPD is reinforced. In addition, a moderating effect of inequality (Gini) was detected.

Efficacy and Safety of Aripiprazole in Borderline Personality Disorder: A Systematic Review

Aripiprazole is an atypical antipsychotic medication, and its use in treating borderline personality disorder (BPD) is debatable because it is not FDA-approved for treating BPD. This study aimed to investigate the efficacy and safety of aripiprazole in patients with BPD. On July 2, 2021, the protocol (CRD42021256647) was registered in PROSPERO. PubMed, Scopus, Web of Science, Ovid-Medline, Embase, PsycINFO, and Cochrane (CENTRAL) were searched without regard for language or publication date. We also searched trial registries on ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. Randomized clinical trials with adult patients diagnosed with BPD met the inclusion criteria. The Cochrane risk of bias for randomized trials (RoB-2) method was used to assess the quality of the included studies. We included two previously published randomized clinical trials. There were 76 patients with BPD, with 38, 12, and 26 assigned to the aripiprazole, olanzapine, and placebo groups, respectively. Most patients (88.16%) were females, with ages ranging from 22.1 to 28.14 yr. Aripiprazole has been proven to reduce anxiety, depression, anger, hostility, clinical severity, and obsessive-compulsive behavior, insecurity, melancholy, anxiety, aggressiveness/hostility, phobic anxiety, paranoid thinking, psychoticism, and somatization. The adverse effects were headache, insomnia, restlessness, tremor, and akathisia. The risk of bias was considerable in both trials, which is somewhat problematic considering that prejudice can lead to incorrect outcomes and conclusions. Aripiprazole has demonstrated encouraging outcomes in the treatment of patients with BPD. More randomized controlled studies are needed.

Mentalizing in Adolescents with Borderline Personality Disorder

Mentalizing, recognized as the capacity to understand behaviors in the context of our own mental states and those of other people, is being researched more and more commonly in regard to various mental disorders. The research on mentalization focuses on, among other things, borderline personality disorder, which is at present perceived as an emerging problem in the population of adolescents. In order to summarize the currently accessible knowledge of mentalizing in adolescents with borderline personality disorder, we thoroughly analyzed relevant publications. Based on the available literature, it can be concluded that the mentalizing ability of adolescents with borderline personality disorder can be impaired. The evidence demonstrates that they are prone to hypermentalizing, defined as an overattribution of mental states to other people. However, this tendency has not been proven to be specific to teenagers with this disorder. Moreover, the existing data suggest that young people with borderline personality exhibit a reduced capacity to mentalize their own inner states.

Neurocognition of females with substance use disorder and comorbid personality disorder: Divergence in subjective and objective cognition

At least one in four patients with substance use disorder (SUD) meet criteria for personality disorder and overlapping neurocognitive deficits may reflect shared neurobiological mechanisms. We studied neurocognition in females attending residential SUD treatment by comparing SUD with (n = 20) or without (n = 30) comorbid personality disorder. Neuropsychological testing included working memory, inhibition, shifting, verbal fluency, design fluency, psychomotor speed, immediate and delayed verbal memory, processing speed, premorbid functioning, cognitive screening, and self-reported executive function. As expected, whole-sample deficits included working memory (d = -.91), self-reported executive function (d = -.87), processing speed (d = -.40), delayed verbal memory recall (d = -.39), premorbid functioning (d = -.51), and cognitive screening performance (d = -.61). Importantly, the comorbid personality disorder group showed greater self-reported executive dysfunction (d = -.67) and poorer shifting performance (d = -.65). However, they also evidenced better working memory (d = .84), immediate (d = .95) and delayed (d = .83) verbal memory, premorbid functioning (d = .90), and cognitive screening performance (d = .77). Overall executive dysfunction deficits were concordant with those observed in previous SUD studies. Surprisingly, comorbid personality disorder was associated with a pattern indicating poorer subjective (self-report) but better objective performance on a number of tasks, apart from shifting deficits that may relate to emotion dysregulation. Subjective emotional dysfunction may influence the cognitive deficits observed in the personality disorder group.

"Feeling Invisible": Individuals With Borderline Personality Disorder Underestimate the Transparency of Their Emotions

The present study investigated transparency estimation, that is, the ability to estimate how observable one's emotions are, in patients diagnosed with borderline personality disorder (BPD) (n = 35) and healthy controls (HCs; n = 35). Participants watched emotionally evocative video clips and estimated the transparency of their own emotional experience while watching the clip. Facial expression coding software (FaceReader) quantified their objective transparency. BPD patients felt significantly less transparent than HCs, but there were no differences in objective transparency. BPD patients tended to underestimate the transparency of their emotions compared to HCs, who in turn overestimated their transparency. This suggests that BPD patients expect that others will not know how they feel, irrespective of how observable their emotions actually are. We link these findings to low emotional awareness and a history of emotional invalidation in BPD, and we discuss their impact on BPD patients' social functioning.

The role of emotional instability in borderline personality disorder: a systematic review

BACKGROUND

The emotional regulation process plays a pivotal role in daily-life functioning, modulating goal-directed and adaptive behavior. Conversely, altering this cognitive function can disrupt self-regulation and bring emotional dysregulation. Emotional instability could represent a core characteristic of BPD, also modulating the BPD symptom's onset. This systematic review aims to summarize the existing literature reporting the role of emotional instability in BPD to better define the role of the impairment of the emotional processes in the onset of the cognitive and behavioral symptoms of this complex mental disorder.

METHODS

MEDLINE, Scopus and Web of Science were independently searched for relevant studies. Eligible studies had to be identifiable through database searching, published and accessible. This systematic review was conducted according to PRISMA guidelines. The search period was from 2012 to 14 September 2022.

RESULTS

A pool of 120 studies was identified, out of which 11 met the selection criteria and were included. Overall, the studies confirm a relationship between emotional instability and borderline personality disorder.

CONCLUSIONS

The evidences retrieved seem to point out the role of the emotional impairment not only in worsening of the disorder, but could also be one of the risk factors for its onset.

Empirical Developments in Transference-Focused Psychotherapy

OBJECTIVE

Transference-focused psychotherapy (TFP) is an empirically supported individualized psychotherapy for patients with borderline personality disorder. This review highlights its development and current status.

METHODS

A review of the theoretical background underpinning TFP and empirical advances in the development of TFP provide perspective.

RESULTS

Otto Kernberg's object relations model of personality and its implications for assessment and diagnosis of personality disorders are described. The authors review the programmatic research that has been developed and has demonstrated the efficacy of TFP. In view of the empirical studies that have demonstrated the successful outcomes and processes of TFP for patients with borderline personality disorder, compared with other approaches, TFP has been applied to a broader range of difficulties related to patients' self-functioning and interpersonal functioning across the range of severities in personality pathology, consistent with the Alternative DSM-5 Model for Personality Disorders. The authors discuss borderline personality organization in the context of interpersonal, neurocognitive, and self-regulatory dysfunction, including preliminary findings.

CONCLUSIONS

The theoretical and empirical advances in TFP lead to future directions for research evaluating personality disorder and its treatment.

Borderline Personality Disorder: A Review

IMPORTANCE

Borderline personality disorder (BPD) affects approximately 0.7% to 2.7% of adults in the US. The disorder is associated with considerable social and vocational impairments and greater use of medical services.

OBSERVATIONS

Borderline personality disorder is characterized by sudden shifts in identity, interpersonal relationships, and affect, as well as by impulsive behavior, periodic intense anger, feelings of emptiness, suicidal behavior, self-mutilation, transient, stress-related paranoid ideation, and severe dissociative symptoms (eg, experience of unreality of one's self or surroundings). Borderline personality disorder is typically diagnosed by a mental health specialist using semistructured interviews. Most people with BPD have coexisting mental disorders such as mood disorders (ie, major depression or bipolar disorder) (83%), anxiety disorders (85%), or substance use disorders (78%). The etiology of BPD is related to both genetic factors and adverse childhood experiences, such as sexual and physical abuse. Psychotherapy is the treatment of choice for BPD. Psychotherapy such as dialectical behavior therapy and psychodynamic therapy reduce symptom severity more than usual care, with medium effect sizes (standardized mean difference) between -0.60 and -0.65. There is no evidence that any psychoactive medication consistently improves core symptoms of BPD. For discrete and severe comorbid mental disorders, eg, major depression, pharmacotherapy such as the selective serotonin reuptake inhibitors escitalopram, sertraline, or fluoxetine may be prescribed. For short-term treatment of acute crisis in BPD, consisting of suicidal behavior or ideation, extreme anxiety, psychotic episodes, or other extreme behavior likely to endanger a patient or others, crisis management is required, which may include prescription of low-potency antipsychotics (eg, quetiapine) or off-label use of sedative antihistamines (eg, promethazine). These drugs are preferred over benzodiazepines such as diazepam or lorazepam.

CONCLUSIONS AND RELEVANCE

Borderline personality disorder affects approximately 0.7% to 2.7% of adults and is associated with functional impairment and greater use of medical services. Psychotherapy with dialectical behavior therapy and psychodynamic therapy are first-line therapies for BPD, while psychoactive medications do not improve the primary symptoms of BPD.

Pathophysiological aspects of complex PTSD - a neurobiological account in comparison to classic posttraumatic stress disorder and borderline personality disorder

Despite a great diagnostic overlap, complex posttraumatic stress disorder (CPTSD) has been recognised by the ICD-11 as a new, discrete entity and recent empirical evidence points towards a distinction from simple posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD). The development and maintenance of these disorders is sustained by neurobiological alterations and studies using functional magnetic resonance imaging (fMRI) may further contribute to a clear differentiation of CPTSD, PTSD and BPD. However, there are no existing fMRI studies directly comparing CPTSD, PTSD and BPD. In addition to a summarization of diagnostic differences and similarities, the current review aims to provide a qualitative comparison of neuroimaging findings on affective, attentional and memory processing in CPTSD, PTSD and BPD. Our narrative review alludes to an imbalance in limbic-frontal brain networks, which may be partially trans-diagnostically linked to the degree of trauma symptoms and their expression. Thus, CPTSD, PTSD and BPD may underlie a continuum where similar brain regions are involved but the direction of activation may constitute its distinct symptom expression. The neuronal alterations across these disorders may conceivably be better understood along a symptom-based continuum underlying CPTSD, PTSD and BPD. Further research is needed to amend for the heterogeneity in experimental paradigms and sample criteria.

Understanding the development of bipolar disorder and borderline personality disorder in young people: a meta-review of systematic reviews

BACKGROUND

There is ongoing debate on the nosological position of bipolar disorder (BD) and borderline personality disorder (BPD). Identifying the unique and shared risks, developmental pathways, and symptoms in emerging BD and BPD could help the field refine aetiological hypotheses and improve the prediction of the onset of these disorders. This study aimed to: (a) systematically synthesise the available evidence from systematic reviews (SRs) and meta-analyses (MAs) concerning environmental, psychosocial, biological, and clinical factors leading to the emergence of BD and BPD; (b) identify the main differences and common features between the two disorders to characterise their complex interplay and, (c) highlight remaining evidence gaps.

METHODS

Data sources were; PubMed, PsychINFO, Embase, Cochrane, CINAHL, Medline, ISI Web of Science. Overlap of included SRs/MAs was assessed using the corrected covered area process. The methodological quality of each included SR and MA was assessed using the AMSTAR.

RESULTS

22 SRs and MAs involving 249 prospective studies met eligibility criteria. Results demonstrated that family history of psychopathology, affective instability, attention deficit hyperactivity disorder, anxiety disorders, depression, sleep disturbances, substance abuse, psychotic symptoms, suicidality, childhood adversity and temperament were common predisposing factors across both disorders. There are also distinct factors specific to emerging BD or BPD.

CONCLUSIONS

Prospective studies are required to increase our understanding of the development of BD and BPD onset and their complex interplay by concurrently examining multiple measures in BD and BPD at-risk populations.

“Esketamine” in Borderline Personality Disorder: A Look Beyond Suicidality

Borderline personality disorder (BPD) is an extremely disabling condition that affects almost every dimension of a patient’s life. The S-enantiomer of ketamine (esketamine) was approved by the Food and Drug Administration (FDA) in 2019 in conjunction with an oral antidepressant for the management of treatment-resistant depression (TRD) in adults. Our patient is a 27-year-old female with a long-standing diagnosis of BPD and treatment-resistant major depressive disorder (MDD) who presented to a tertiary care hospital after a baleful suicide attempt. As per treatment guidelines, “esketamine” intranasal spray in conjunction with citalopram 20 mg was started in the outpatient setting at a dose of 56 mg twice weekly for four weeks, followed by 56 mg once weekly, which was further titrated to 84 mg once weekly. Two years into treatment, the patient and her mother report around 70% improvement in her depression and anxiety with around 80% improvement in her behavioral symptoms. Esketamine’s potential action on patients with BPD can be partially explained by its very well-documented effect on the glutamate receptor antagonism. Additionally, patients with stress-induced suicidal ideations (SI), which are seen in borderline patients, are better responsive to ketamine. In conclusion, we recommend a trial of intranasal esketamine in patients with BPD with treatment-resistant MDD and frequent episodes of self-harm. Treatment with esketamine could potentially reduce the number of emergency room visits for impulsive suicide attempts and help reduce the life burden of BPD and its impact on family members.

Adolescents with borderline personality disorder show a higher response to stress but a lack of self-perception: Evidence through affective computing

Stress reactivity is a complex phenomenon associated with multiple and multimodal expressions and functions. Herein, we hypothesized that compared with healthy controls (HCs), adolescents with borderline personality disorder (BPD) would exhibit a stronger response to stressors and a deficit in self-perception of stress due to their lack of insight. Twenty adolescents with BPD and 20 matched HCs performed a socially evaluated mental arithmetic test to induce stress. We assessed self- and heteroperception using both human ratings and affective computing-based methods for the automatic extraction of 39 behavioral features (2D + 3D video recording) and 62 physiological features (Nexus-10 recording). Predictions were made using machine learning. In addition, salivary cortisol was measured. Human ratings showed that adolescents with BPD experienced more stress than HCs. Human ratings and automated machine learning indicated opposite results regarding self- and heteroperceived stress in adolescents with BPD compared to HCs. Adolescents with BPD had higher levels of heteroperceived stress than self-perceived stress. Similarly, affective computing achieved better classification for heteroperceived stress. HCs had an opposite profile; they had higher levels of self-perceived stress, and affective computing reached a better classification for self-perceived stress. We conclude that adolescents with BPD are more sensitive to stress and show a lack of self-perception (or insight). In terms of clinical implications, our affective computing measures may help distinguish hetero- vs. self-perceptions of stress in natural settings and may offer external feedback during therapeutic interaction.

A double-blind placebo-controlled study of brexpiprazole for the treatment of borderline personality disorder

BACKGROUND

Borderline personality disorder is associated with impaired quality of life and has a number of untoward public health associations. There is no established first-line pharmacological treatment for borderline personality disorder, and available options are not suitable for all individuals.

AIMS

To evaluate brexpiprazole, which has effects on the dopaminergic and serotonergic systems, for the reduction of borderline personality disorder symptoms.

METHOD

Eighty adults with borderline personality disorder were recruited for a randomised, double-blind placebo-controlled study. Participants received 12-week treatment with brexpiprazole (1 mg/day for 1 week, then increasing to 2 mg/day) or placebo in a parallel design. The primary efficacy outcome measure was the clinician-rated Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD). Safety data were collected. Effects of active versus placebo treatment were characterised with linear repeated measures models.

RESULTS

There was a significant interaction between treatment and time on the ZAN-BPD scale (P = 0.0031), solely because of differentiation specifically at week 12. Brexpiprazole was generally well tolerated. Secondary measures did not result in statistically significant differences from placebo.

CONCLUSIONS

Brexpiprazole appears to have some possible effect on borderline personality disorder symptoms, but further studies are needed because of the significant effects evident, specifically at the final time point. These findings also need to be viewed cautiously, given the small sample size, large drop-out rate and robust placebo response.

Repetitive transcranial magnetic stimulation in patients with borderline personality disorder: A systematic review

The literature on the application of repetitive transcranial magnetic stimulation (rTMS) in Borderline Personality Disorder (BPD) is unclear, even though its neuromodulatory effects on underlying neural circuitry involved in BPD symptoms suggest that it could be a potential treatment option. We sought to review the evidence on rTMS as a treatment option in BPD. PubMed (for Medline database), Google Scholar, and Scopus were systematically searched following the PRISMA guidelines for studies of any design examining the application of the rTMS treatment in adult patients with precise and primary diagnosis of BPD written in the English language. The systematic review has been registered on PROSPERO (CRD42020215927). Forty one records were screened, and eight fulfilled inclusion criteria (total of 63 patients). The existing studies suggest that rTMS is a well-tolerated treatment in patients with BPD. Double-blind randomized controlled studies are necessary to help elucidate the effects of rTMS in the different symptoms in BPD and establish efficacy and the best cortical targets and stimulation protocols. Longitudinal studies that combine evidenced based psychotherapy with rTMS may be a future line of investigation that could potentially improve outcomes for this population.

Persistent idiopathic facial pain associated with borderline personality disorder: a case report

IntroductionBorderline personality disorder may be associated with persistent facial pain since its relationship with different pain syndromes has been reported. Persistent idiopathic facial pain is commonly unilateral, pulsating, burning, or profound and challenging for clinicians. Therefore, excluding underlying organic causes by appropriate clinical investigation and complementary tests is essential to diagnose this disease.Objective This case report aimed to provide evidence of the relationship between idiopathic persistent facial pain and borderline personality disorder.Case report A 24-year-old woman reported severe pain in the left hemiface for ten months, three to six hours per day, five days per week. No abnormalities were found in dental and neurological assessments. A psychiatric evaluation was performed, and the patient met the criteria for borderline personality disorder. Pharmacological treatment consisted of daily lithium carbonate (900 mg) and venlafaxine (150 mg). Weekly sessions of cognitive-behavioral therapy with emotional regulation and tolerance to stress were performed. The patient was evaluated every 30 days and showed improved pain intensity and frequency over six months. Conclusion Proper management of borderline personality disorder can modify the evolution of persistent idiopathic facial pain when both pathologies are comorbidities.

Alcohol use patterns and disorders among individuals with personality disorders in the Sao Paulo Metropolitan Area

Introduction

Alcohol Use Disorders are frequently comorbid with personality disorders. However, the heterogeneity of the prevalence estimates is high, and most data come from high income countries. Our aim is to estimate the prevalence and association between alcohol use outcomes and the three DSM-5 clusters of personality disorders in a representative sample of the São Paulo Metropolitan Area.

Materials and methods

A representative household sample of 2,942 adults was interviewed using the WHO Composite International Diagnostic Interview and the International Personality Disorder Examination Screening Questionnaire. Lifetime PD diagnoses were multiply imputed, and AUD diagnoses were obtained using DSM-5 criteria. We conducted cross-tabulations and logistic regression to estimate the associations between AUDs and PDs.

Results and discussion

Our study did not find significant associations of PDs with heavy drinking patterns or mild AUD. Cluster B PD respondents tended to show the highest conditional prevalence estimates of most alcohol use patterns and AUD, including its severity subtypes. When alcohol outcomes were regressed on all PD Clusters simultaneously, with adjustment for sex and age, only cluster B was significantly associated with past-year alcohol use (OR 3.0), regular drinking (OR 3.2), and AUDs (OR 8.5), especially moderate and severe cases of alcohol use disorders (OR 9.7 and 16.6, respectively). These associations between Cluster B PDs and these alcohol outcomes were shown to be independent of other PD Clusters and individuals´ sex and age.

Conclusion

The main finding of our study is that AUDs are highly comorbid with PDs. The presence of Cluster B PDs significantly increases the odds of alcohol consumption and disorders and of more severe forms of AUDs. Considering the local context of poor treatment provision, more specific prevention and intervention strategies should be directed to this population.

The neurobiology of human aggressive behavior: Neuroimaging, genetic, and neurochemical aspects

In modern societies, there is a strive to improve the quality of life related to risk of crimes which inevitably requires a better understanding of brain determinants and mediators of aggression. Neurobiology provides powerful tools to achieve this end. Pre-clinical and clinical studies show that changes in regional volumes, metabolism-function and connectivity within specific neural networks are related to aggression. Subregions of prefrontal cortex, insula, amygdala, basal ganglia and hippocampus play a major role within these circuits and have been consistently implicated in biology of aggression. Genetic variations in proteins regulating the synthesis, degradation, and transport of serotonin and dopamine as well as their signal transduction have been found to mediate behavioral variability observed in aggression. Gene-gene and gene-environment interactions represent additional important risk factors for aggressiveness. Considering the social burden of pathological forms of aggression, more basic and translational studies should be conducted to accelerate applications to clinical practice, justice courts, and policy making.

Neural Changes in Borderline Personality Disorder After Dialectical Behavior Therapy-A Review

The biological component of the biosocial theory of emotion regulation stipulates that borderline personality disorder (BPD) arises from biological vulnerabilities to heightened emotional reactivity. Comprehensive reviews have consistently implicated abnormalities in the amygdala, anterior cingulate cortex, and hippocampus in the neurobiology of BPD. While Dialectical Behavior Therapy (DBT) is the leading evidence-based psychotherapy for the treatment of BPD, there remains a paucity of literature examining changes in the neurobiology of BPD following DBT treatment. Nine studies were identified that examined neurobiological changes in BPD after the completion of DBT. Results indicated that there was significant deactivation of amygdala activity as well as the anterior cingulate cortex in patients with BPD after DBT treatment. As well, several studies found after DBT treatment, BPD patients had a decreased activity in the inferior frontal gyrus in response to arousing stimuli and increased activity in response to inhibitory control. Future research on the neurobiological change after DBT treatment can help clarify biological mechanisms of change in BPD.

Brain Connectivity and Symptom Changes After Transcranial Magnetic Stimulation in Patients With Borderline Personality Disorder

OBJECTIVES

Repetitive transcranial magnetic stimulation (rTMS) is an innovative method in the treatment of borderline personality disorder (BPD). We hypothesized that prefrontal rTMS in patients with BPD leads to improved BPD symptoms and that these effects are associated with brain connectivity changes.

METHODS

Fourteen patients with BPD received 15 sessions of individually navigated prefrontal rTMS over the right dorsolateral prefrontal cortex. Clinical effects were measured by the Borderline Symptom List 23, UPPS-P, the Difficulties in Emotion Regulation Scale (DERS), the Zung Self-Rating Anxiety Scale (SAS), and the Montgomery and Åsberg Depression Rating Scale (MADRS). Effects of rTMS on brain connectivity were observed with a seed correlation analysis on resting-state fMRI and with a beta series correlation analysis on Go/No Go tasks during fMRI. Assessments were made before and immediately after the treatment.

RESULTS

The assessments after rTMS showed significant reductions in two subscales of UPPS-P, and in DERS, SAS, and MADRS. The brain connectivity analysis revealed significant decreases in amygdala and insula connectivity with nodes of the posterior default mode network (pDMN; precuneus, posterior cingulate cortex, parietal lobules). Connectivity changes were observed both in the resting state and during inhibition. The decrease of amygdala-pDMN connectivity was positively correlated with reduced depression and lack of premeditation after rTMS.

CONCLUSIONS

Despite the study limitations (open single-arm study in a small sample), our findings suggest a possible neural mechanism of rTMS effect in BPD, reduced amygdala connectivity with the pDMN network, which was positively associated with symptom reduction.

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

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

Can transcranial direct current stimulation (tDCS) improve impulsivity in healthy and psychiatric adult populations? A systematic review

Impulsivity is a multidimensional phenomenon that remains hard to define. It compounds the core pathological construct of many neuropsychiatric illnesses, and despite its close relation to suicide risk, it currently has no specific treatment. Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique whose application results in cognitive function improvement, both in healthy and psychiatric populations. Following PRISMA recommendations, a systematic review of the literature concerning tDCS's effects on impulsive behaviour was performed using the PubMed database. The research was based on the combination of the keyword 'tDCS' with 'impulsivity', 'response inhibition', 'risk-taking', 'planning', 'delay discounting' or 'craving'. The initial search yielded 309 articles, 92 of which were included. Seventy-four papers demonstrated improvement in task performance related to impulsivity in both healthy and clinical adult populations. However, results were often inconsistent. The conditions associated with improvement, such as tDCS parameters and other aspects that may influence tDCS's outcomes, are discussed. The overall effects of tDCS on impulsivity are promising. Yet further research is required to develop a more comprehensive understanding of impulsivity, allowing for a more accurate assessment of its behavioural outcomes as well as a definition of tDCS therapeutic protocols for impulsive disorders.

The Limits between Bipolar Disorder and Borderline Personality Disorder: A Review of the Evidence

Bipolar disorder and borderline personality disorder are among the most frequently diagnosed psychiatric conditions. However, the nosological aspects and diagnostic boundaries of both conditions have historically been the object of considerable controversy. The present paper critically analyzes this debate, in light of available evidence. Clinical and neurobiological differences between bipolar disorder and borderline personality disorder are discussed, as well as the factors possibly involved in the overlap between both conditions and the potential implications of this.