Clinical improvement in patients with borderline personality disorder after treatment with repetitive transcranial magnetic stimulation: preliminary results

Efficacy of transcranial magnetic stimulation treatment in reducing neuropsychiatric symptomatology after traumatic brain injury

Background

Neuropsychiatric disorders are highly disabling in traumatic brain injury (TBI) patients, and psychopharmacological treatments often fail to adequately mitigate their detrimental effects. Repetitive transcranial magnetic stimulation (rTMS) is an emerging treatment in neurology and psychiatry, showing potential in treating psychiatric disorders.

Objective

This study investigates the efficacy of a novel, dual-site sequential rTMS protocol designed to treat neuropsychiatric symptoms in a TBI patient who was refractory to conventional treatments.

Methods

A 34-year-old woman with severe head trauma and complex psychopathology underwent 20 daily sessions of focal-coil rTMS, combining inhibitory stimulation (1 Hz) on the right dorsolateral prefrontal cortex (DLPFC) and excitatory (10 Hz) on the left DLPFC, guided by a neuronavigation system. Psychiatric and neurocognitive assessments were conducted at baseline and at 2, 4, and 8 weeks following the beginning of rTMS treatment.

Results

After 2 weeks of treatment, the patient showed decreased impulsivity and obsessive-compulsive symptoms, along with improvements in attention and processing speed. After 4 weeks, impulsivity further declined, though no other significant changes were noted. At 8 weeks, a persistent positive effect was observed, including enhanced positive emotions.

Discussion

These findings suggest that guided, alternating neurostimulation of the DLPFC may modulate activity within cortico-striato-thalamo-cortical circuits, providing a promising alternative for managing neuropsychiatric symptoms in TBI patients who are resistant to traditional treatments.

Effects of intermittent theta burst stimulation add-on to dialectical behavioral therapy in borderline personality disorder: results of a randomized, sham-controlled pilot trial

Dialectical behavioral therapy (DBT) and repetitive transcranial magnetic stimulation (rTMS) are both effective in borderline personality disorder (BPD). We hypothesized that intermittent theta burst stimulation (iTBS), a modified rTMS protocol that provides unilateral stimulation to the left dorsolateral prefrontal cortex, would enhance the effects of DBT and reduce BPD-specific symptoms more than sham stimulation. We performed a single-blind, randomized, sham-controlled pilot study to evaluate iTBS as an add-on to 8-week DBT for BPD in routine inpatient treatment. A total of 53 BPD patients were randomly assigned to either iTBS (n = 25) or sham stimulation (n = 28) in weeks 4-8 of DBT; 40 patients were eligible for inclusion in the analyses according to pre-specified criteria (≥ 16 of 20 iTBS sessions). The primary endpoint was change on the 23-item Borderline Symptom List; secondary endpoints were changes in depressive symptoms and general level of functioning. A mixed model repeated measures analysis with a 2 × 2 factorial between-subjects design showed no significant effect of add-on iTBS treatment, but a distinct trend was observed in favor of iTBS (Cohen's d = 0.23 for group difference). We found a main effect of DBT with and without iTBS over time, indicating efficacy of 8 weeks' DBT (d = 0.89-1.12). iTBS may be beneficial as an add-on to DBT in the long term and warrants further evaluation in larger studies. Trial registration Registered at drks.de (no. DRKS00020413) on January 13, 2020.

What impact can brain stimulation interventions have on borderline personality disorder?

INTRODUCTION

Borderline personality disorder (BPD) is a severe mental disorder characterized by emotion dysregulation, impulsivity, neuropsychological impairment, and interpersonal instability, presenting with multiple psychiatric comorbidities, functional disability and reduced life expectancy due suicidal behaviors.

AREAS COVERED

In this perspective, the authors explore the application of noninvasive brain stimulation (NIBS) (rTMS, tDCS, and MST) in BPD individuals by considering a symptom-based approach, focusing on general BPD psychopathology, impulsivity and neuropsychological impairments, suicidality and depressive/anxious symptoms, and emotion dysregulation.

EXPERT OPINION

According to a symptoms-based approach, NIBS interventions (particularly rTMS and tDCS) are promising treatment options for BPD individuals improving core symptoms such as emotional and behavioral dysregulation, neuropsychological impairments and depressive symptoms. However, the heterogeneity of stimulation protocols and of assessment tools used to detect these changes limits the possibility to provide definitive recommendations according to a symptom-based approach. To implement such armamentarium in clinical practice, future NIIBS studies should further consider a lifespan perspective due to clinical variability over time, the role of psychiatric comorbidities affecting BPD individuals and the need to combine NIBS with specialized psychotherapeutic approaches for BPD patients and with functional neuroimaging studies.

Theta burst stimulation add on to dialectical behavioral therapy in borderline-personality-disorder: methods and design of a randomized, single-blind, placebo-controlled pilot trial

Specialized psychotherapeutic treatments like dialectical behavioral therapy (DBT) are recommended as first treatment for borderline personality disorder (BPD). In recent years, studies have emerged that focus on repetitive transcranial magnetic stimulation (rTMS) in BPD. Both have independently demonstrated efficacy in the treatment of BPD. Intermitted theta burst stimulation (iTBS), a modified design of rTMS, is thought to increase the excitability of neurons and could be a supplement to psychotherapy in addition to being a standalone treatment. However, no studies to date have investigated the combination of DBT and rTMS/iTBS. This study protocol describes the methods and design of a randomized, single-blinded, sham-controlled clinical pilot study in which BPD patients will be randomly assigned to either iTBS or sham during four consecutive weeks (20 sessions in total) in addition to standardized DBT treatment. The stimulation will focus on the unilateral stimulation of the left dorsolateral prefrontal cortex (DLPFC), which plays an important role in the control of impulsivity and risk-taking. Primary outcome is the difference in borderline symptomatology, while secondary target criteria are depressive symptoms, general functional level, impulsivity and self-compassion. Statistical analysis of therapy response will be conducted by Mixed Model Repeated Measurement using a 2 × 2-factorial between-subjects design with the between-subject factor stimulation (TMS vs. Sham) and the within-subject factor time (T0 vs. T1). Furthermore, structural magnetic resonance imaging (MRI) will be conducted and analyzed. The study will provide evidence and insight on whether iTBS has an enhancing effect as add-on to DBT in BPD.Trial registration: drks.de (DRKS00020413) registered 13/01/2020.

Psychosocial and pharmacological interventions for personality disorders in low- and middle-income countries: A systematic review

Personality disorders (PDs) have a global prevalence of 7.8% and are associated with increased rates of morbidity and mortality. Most research on PDs has been conducted in High Income Countries (HICs). We conducted a systematic review to investigate the effectiveness of psychosocial and pharmacological interventions for personality disorders (PDs) in individuals from Low- and Middle-Income Countries (LMICs.) We systematically searched MEDLINE, Embase, APA PsycInfo, Web of Science, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and The Cochrane Library from inception to January 5, 2023. Inclusion criteria were quantitative studies and grey literature where participants received a psychosocial or pharmacological intervention for PD. Exclusion criteria were qualitative studies, review articles, studies in which PD was not the primary condition, and articles not available in English. The Cochrane Risk of Bias tool version 2.0 and Joanna Briggs Institute instruments were used to measure risk of bias. Studies were pooled by type of study, PD investigated, type of intervention, assessment methods, and outcomes. Sixteen studies met inclusion criteria and were included. Fifteen were intervention studies related to borderline PD. Only one studied mixed PDs. Twelve studies were of psychotherapy, one pharmacotherapy, one combination of both, and two neurostimulation. Most of the studies showed improvement in symptoms though data was largely collected using self-report measures. There were only six RCTs. There is a dearth of literature on interventions for PDs in LMICs and funding bodies should prioritize research in LMICs. Systematic Review Registration Number: PROSPERO CRD42021233415.

Exploring the Utility of Neurostimulation Therapies in the Treatment of Borderline Personality Disorder: A Systematic Literature Review

ABSTRACT

The use of electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) in the treatment of people diagnosed with borderline personality disorder (BPD) highlights the need for systematic review of the evidence supporting this practice. A comprehensive literature search identified seven original clinical research studies investigating the use of brain stimulation therapies in people diagnosed with BPD. The lack of consistent study design, diagnostic methodology, treatment parameters, and outcome measures precluded analysis of aggregated study results. There were no ECT studies evaluating BPD symptom outcomes; however, studies of ECT in patients with comorbid BPD and depression suggested that depressive symptoms were less responsive to ECT compared with depression-only patients. The few studies available suggest that TMS may lead to clinically and statistically significant improvements in BPD symptoms and depressive symptoms. Similar overall improvements were reported despite the use of heterogeneous TMS treatment protocols, highlighting the importance of including a sham condition to investigate the contribution of the placebo effect to overall improvement. There is still no clear evidence supporting the use of ECT for treating people with BPD (with or without depression); therefore, the use of ECT in this population should be approached with caution. Although TMS shows early promise, the low numbers of participants in the few available studies suggest the urgent need for larger randomized controlled trials to provide an evidence base for this increasingly popular treatment.

Efficacy of Noninvasive Brain Stimulation on Borderline Personality Disorder Core Symptoms: A Systematic Review

Although psychotherapy is the first-line treatment of borderline personality disorder (BPD), psychopharmacological agents have not been approved yet. Modulating brain functions with noninvasive brain stimulation (NIBS) interventions, such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), may have a role in the treatment of BPD. In light of the limited knowledge available and the emerging interest in the possible role of NIBS as a therapeutic tool, the authors' main aim is to systematically review the literature on the effect of both rTMS and tDCS on BPD symptoms, specifically affective dysregulation, impulsive-behavioral dyscontrol, and cognitive-perceptual difficulties. The review process was conducted in accordance with PRISMA guidelines. The research methods were registered on PROSPERO (id code CRD42020209491). Eleven studies were included in the review. Despite the limited number of studies retrieved, preliminary data showed an improvement in all domains. Further studies are needed to understand potential long-term advantages of NIBS.

Efficacy and tolerability of Brain Stimulation interventions in Borderline Personality Disorder: state of the art and future perspectives - A systematic review

Treating Borderline Personality Disorder (BPD) is a major challenge for psychiatrists. As Brain Stimulation represents an alternative approach to treat psychiatric disorders, our systematic review is the first to focus on both invasive and Non-Invasive Brain Stimulation (NIBS) interventions in people living with BPD, examining clinical effects over core features and comorbid conditions. Following PRISMA guidelines, out of 422 original records, 24 papers were included regarding Deep Brain Stimulation (n = 1), Electroconvulsive therapy (n = 5), Transcranial Magnetic Stimulation (n = 13) and transcranial Direct Current Stimulation (n = 5). According to impulsivity and emotional dysregulated domain improvements, NIBS in BPD appears to restore frontolimbic network deficiencies. NIBS seems also to modulate depressive features. Safety and tolerability profiles for each technique are discussed. Despite encouraging results, definitive recommendations on Brain Stimulation in BPD are mitigated by protocols heterogeneity, lack of randomized controlled trials and poor quality of included studies, including high risk of methodological biases. To serve as guide for future systematic investigations, protocols optimization proposals are provided, focusing on alternative stimulation sites and suggesting a NIBS symptom-based approach.

Non-invasive neuromodulation can reduce aggressive behaviors in humans: A critical perspective

Containing aggressive behavior is an ongoing challenge in modern society. Aggressiveness is a multi-level construct that can be driven by emotions (reactive aggression) or can be "cold-blooded" and goal-directed (proactive). Aggressive behavior could arise because of a misjudgment of others' intentions or can follow frontal brain lesions leading to a reduction of impulse control and emotion regulation. In the last few years, interventional and basic research studies adopting Non-Invasive Brain Stimulation (NIBS) have significantly risen. Those techniques have been used both in healthy people, to better understand the role of certain brain regions in psychological processes, and in aggressive subjects to improve their symptoms. From an overview of the literature, focusing on the paper that uses transcranial direct current stimulation (tDCS) to reduce aggressiveness, it emerges that tDCS can (i) enhance facial emotion expression recognition, (ii) improve impulses control, and (iii) affect approach/withdrawal motivation. The current work shows the strengths and weaknesses of tDCS intervention on aggressive individuals, suggesting that this instrument could be adopted on violent people, and paves the way for intervention in some applied settings such as prison.

Dorsomedial prefrontal rTMS for depression in borderline personality disorder: A pilot randomized crossover trial

BACKGROUND

Recently, a small literature has emerged suggesting that repetitive transcranial magnetic stimulation (rTMS) may offer benefit for MDD even in BPD patients, perhaps by enhancing cognitive control, and/or disrupting excessive 'non-reward' activity in right orbitofrontal regions. This study aimed primarily to assess the therapeutic effects of dorsomedial prefrontal cortex (DMPFC)-rTMS against MDD symptoms in BPD patients, and secondarily to assess whether the therapeutic effects ensued via mechanisms of reduced impulsivity and core BPD pathology on clinical scales (BIS-11, ZAN-BPD) or of reduced alpha- and theta-band activity on EEG recordings of right orbitofrontal cortex..

METHODS

In a crossover-design trial, 20 BPD patients with MDD underwent 2 × 30 session/15 day blocks of either active-then-sham or sham-then-active bilateral 20 Hz DMPFC-rTMS.

RESULTS

Sixteen out of 20 patients completed treatment. A significant (p = 0.00764) crossover effect was detected, with overall reductions in HamD17 score from 23.1±SD3.1 to 10.75±SD5.8. Nine out of 16 (56.3%) treatment completers achieved response (>50% improvement) and 6/16 (37.5%) achieved remission (HamD≤7), maintained at 1 month followup. BIS-11 scores remained unchanged, and ZAN-BPD scores improved similarly in both groups with no significant crossover effect. Change in low-band power over right orbitofrontal regions correlated with clinical improvement.

LIMITATIONS

This was a crossover study with a small sample size. A randomized controlled trial with larger sample size will be needed to establish the efficacy more definitively.

CONCLUSIONS

The results suggest efficacy for DMPFC-rTMS in treating MDD in BPD, and provide a foundation for a larger future trial.

Modulating Behavioural and Self-Reported Aggression with Non-Invasive Brain Stimulation: A Literature Review

Aggressive behaviour is at the basis of many harms in society, such as violent crime. The efforts to explain, study, and possibly reduce aggression span various disciplines, including neuroscience. The specific brain networks which are involved in the modulation of aggressive behaviour include cortical asymmetry and brain areas such as the dorsolateral prefrontal cortex (DLPFC), the ventrolateral prefrontal cortex (VLPFC), and the ventromedial prefrontal cortex (VMPFC). Recent non-invasive brain stimulation (NIBS) research suggests that both transcranial direct current stimulation (tDCS) and continuous theta burst stimulation (cTBS) can play a role in the modulation of aggressive behaviour by directly changing brain activity. In this review, we systematically explore and discuss 11 experimental studies that aimed to modulate aggressive behaviour or self-reported aggression using NIBS. Out of these 11 studies, nine significantly up- or downregulated aggression by using tDCS or cTBS targeting the DLPFC, VLPFC or VMPFC. The potential applications of these findings span both the clinical and the forensic psychological domains. However, the results are limited by the methodological heterogeneity in the aggression measures used across the studies, and by their generally small sample sizes. Future research should consider improving the localization and specificity of NIBS by employing neuro-navigational instruments and standardized scoring methods.

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.

Validity and Reliability of the Urdu Version of the McLean Screening Instrument for Borderline Personality Disorder

Introduction: Although the translation and the validation of the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) are performed in various languages and samples, no study has established the validity and reliability of the Urdu version of MSI-BPD in individuals with cardiac problems. Materials and Methods: The Urdu version of the MSI-BPD was prepared through the standard back-translation method. The translation and adaption were completed in four steps: forward translation, adaption and translation, back translation and committee approach, and cross-language validation. The sample, selected through the purposive sampling method, comprised of 150 adults with cardiac problems (men = 75 and women = 75), with an age range of 23-78 years (M = 55, SD = 10.6). The Cronbach alpha reliability and factorial validity of the MSI-BPD were assessed through confirmatory factor analysis (CFA) and Pearson correlation analyses. Internal consistency and test-retest reliability (at 2 weeks' interval) were used to evaluate the reliability. Statistical analyses were performed, using SPSS (version 22) and Structural Equation Modeling (SEM) software. Results: Preliminary analysis revealed that the overall instrument had good internal consistency (Urdu MSI-BPD α = 0.79; English MSI-BPD α = 0.77) as well as test-retest correlation coefficients for 15 days (r = 0.94). Conclusions: Findings suggested that the MSI-BPD, with important limitations, can be used as an effective preliminary screening tool to measure BPD in Urdu-speaking adults with cardiac problems. Further validations should be conducted to make the translated version of the MSI-BPD an appropriate tool to screen BPD in hospitals and mental health care settings.

Neuromodulatory treatments for psychiatric disease: A comprehensive survey of the clinical trial landscape

BACKGROUND

Numerous neuromodulatory therapies are currently under investigation or in clinical use for the treatment of psychiatric conditions.

OBJECTIVE/HYPOTHESIS

We sought to catalogue past and present human research studies on psychiatric neuromodulation and identify relevant trends in this field.

METHODS

ClinicalTrials.gov (https://www.clinicaltrials.gov/) and the International Clinical Trials Registry Platform (https://www.who.int/ictrp/en/) were queried in March 2020 for trials assessing the outcome of neuromodulation for psychiatric disorders. Relevant trials were categorized by variables such as neuromodulation modality, country, brain target, publication status, design, and funding source.

RESULTS

From 72,086 initial search results, 1252 unique trials were identified. The number of trials registered annually has consistently increased. Half of all trials were active and a quarter have translated to publications. The largest proportion of trials involved depression (45%), schizophrenia (18%), and substance use disorders (14%). Trials spanned 37 countries; China, the second largest contributor (13%) after the United States (28%), has increased its output substantially in recent years. Over 75% of trials involved non-convulsive non-invasive modalities (e.g., transcranial magnetic stimulation), while convulsive (e.g., electroconvulsive therapy) and invasive modalities (e.g., deep brain stimulation) were less represented. 72% of trials featured approved or cleared interventions. Characteristic inter-modality differences were observed with respect to enrollment size, trial design/phase, and funding. Dorsolateral prefrontal cortex accounted for over half of focal neuromodulation trial targets. The proportion of trials examining biological correlates of neuromodulation has increased.

CONCLUSION(S)

These results provide a comprehensive overview of the state of psychiatric neuromodulation research, revealing the growing scope and internationalism of this field.

Challenging control over emotions in borderline personality disorder - a tDCS study

BACKGROUND

Deficient cognitive control (CC) over emotional distraction is a central characteristic of borderline personality disorder (BPD). Reduced activation of the left dorsolateral prefrontal cortex (dlPFC) has been linked to this deficit. This study investigates whether it is possible to ameliorate CC deficits via anodal tDCS over the left dlPFC in BPD. Furthermore, we investigate whether the extent of CC impairment influences how well one responds to tDCS.

METHODS

The effect of a single-session tDCS (1 mA for 20 min, reference electrode on the contralateral mastoid bone) to the left dlPFC (F3) on the CC of patients with BPD (N = 20) and healthy control participants (HCs, N = 20) was examined in a double-blinded, balanced randomized, sham-controlled crossover trial. A delayed response working memory task with negative, neutral and positive pictures presented during the delay period was conducted to assess CC. Stimulation was applied simultaneously with the task.

RESULTS

Negative pictures caused prolonged response times as compared to a control condition in patients with BPD and HCs. Anodal tDCS to the left dlPFC did not significantly reduce this interference effect in the overall sample. Further analyses showed, however, that participants with impaired CC profited the most from anodal tDCS. In the subgroup of participants who actually showed an interference effect we found the expected significant amelioration of CC under tDCS.

CONCLUSIONS

The present study demonstrates that anodal tDCS applied to the left dlPFC improves deficient CC. Thereby, base-level performance moderates tDCS effects. Hence, tDCS might be suitable to support behavioral trainings to enhance CC specifically in people whose impairments in CC are comparably high.

Borderline personality traits do not influence response to TMS

Comorbid personality disorders are common in patients with major depressive disorder (MDD). Individuals with comorbid borderline personality disorder (BPD) may be less responsive to electroconvulsive therapy (ECT), but it remains unclear whether BPD affects responsiveness to transcranial magnetic stimulation (TMS). We sought to investigate the association between BPD and response to TMS. We conducted a retrospective analysis of individuals receiving TMS (n=356) at McLean Hospital. We also included individuals receiving ECT (n=1434) as a control. All individuals completed the McLean Screening Instrument for BPD (MSI-BPD) at baseline. Response to treatment was measured by the Quick Inventory of Depression Symptomatology Self-Report (QIDS-SR). We performed general linear models (GLMs) to assess the effect of BPD on treatment response to TMS and ECT. At baseline, the ECT group had a higher average QIDS-SR score (21.4 vs. 20.3, p<0.05). For both treatment groups, the number of treatments had a significant effect on depression severity. For the TMS group, there was no significant Group x Time interaction on QIDS-SR score (p=0.18). However, for individuals receiving ECT, there was a significant Group x Time interaction on QIDS-SR score (p=0.02), suggesting that BPD significantly impaired response. These results suggest that borderline personality traits did not affect treatment response to TMS for MDD. BPD traits modestly predicted response to ECT, which is consistent with the literature. These results require replication in a clinical trial.

Improvement in borderline personality disorder symptomatology after repetitive transcranial magnetic stimulation of the dorsomedial prefrontal cortex: preliminary results

Objective:

Current treatment for borderline personality disorder (BPD) involves psychological and pharmacological interventions. However, neuromodulation techniques such as repetitive transcranial magnetic stimulation (rTMS) may positively affect BPD symptomatology. The objective of this study was to evaluate the clinical and neuropsychological effects of rTMS on the dorsomedial prefrontal cortex (DMPFC) in BPD patients.

Methods:

Fourteen patients with BPD were randomized into two groups (active vs. sham) for 15 sessions of rTMS on the DMPFC. Clinical effects were measured using the Borderline Symptoms List (BSL), Clinical Global Impression Scale for BPD (CGI-BPD), Borderline Evaluation of Severity over Time (BEST), Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), and Barratt’s Impulsiveness Scale (BIS). Neuropsychological effects were determined by a Stop-Signal Task (SST), the Wisconsin Card-Sorting Test (WCST), and the Iowa Gambling Test (IGT).

Results:

Within-group comparison showed significant differences (p < 0.05) in CGI-BPD (total score and six of nine psychopathologic domains), BEST, HDRS, HARS, and IGT scores for active modality.

Conclusion:

The 5 Hz-DMPFC rTMS technique was well tolerated and lessened the severity of BPD symptomatology, especially abandonment, affective issues, interpersonal relationships, suicidal behavior, anger, and paranoid ideation. Cognitive improvement was seen in decision-making. Additional studies are needed to fully evaluate the effects of rTMS on BPD symptomatology.

Clinical Trial Registration:

NCT03832777.

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 Effects of Repetitive Transcranial Magnetic Stimulation on Anxiety in Patients With Moderate to Severe Traumatic Brain Injury: A Post-hoc Analysis of a Randomized Clinical Trial

Background: Traumatic brain injury (TBI) is one of the leading causes of neuropsychiatric disorders in young adults. Repetitive Transcranial Magnetic Stimulation (rTMS) has been shown to improve psychiatric symptoms in other neurologic disorders, such as focal epilepsy, Parkinson's disease, and fibromyalgia. However, the efficacy of rTMS as a treatment for anxiety in persons with TBI has never been investigated. This exploratory post-hoc analyzes the effects of rTMS on anxiety, depression and executive function in participants with moderate to severe chronic TBI. Methods: Thirty-six participants with moderate to severe TBI and anxiety symptoms were randomly assigned to an active or sham rTMS condition in a 1:1 ratio. A 10-session protocol was used with 10-Hz rTMS stimulation over the left dorsolateral prefrontal cortex (DLPFC) for 20 min each session, a total of 2,000 pulses were applied at each daily session (40 stimuli/train, 50 trains). Anxiety symptoms; depression and executive function were analyzed at baseline, after the last rTMS session, and 90 days post intervention. Results: Twenty-seven participants completed the entire protocol and were included in the post-hoc analysis. Statistical analysis showed no interaction of group and time (p > 0.05) on anxiety scores. Both groups improved depressive and executive functions over time, without time and group interaction (p _s < 0.05). No adverse effects were reported in either intervention group. Conclusion: rTMS did not improve anxiety symptoms following high frequency rTMS in persons with moderate to severe TBI. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02167971.

Impulsivity and its Therapeutic Management in Borderline Personality Disorder: a Systematic Review

No treatment has been approved and recognized as effective in borderline personality disorder (BPD). Impulsivity is a key dimension because it is a predictor of remission but also suicide. The purpose of this review is to establish an inventory on the management of impulsivity in BPD and determine the effective treatments. A systematic review on the PubMed and Ovid databases was conducted up to September 2019 to December 2019 using the PRISMA guidelines. The inclusion criteria were: studies with patients with borderline personality disorder, were published between 1989 and 2019, used English-language and evaluated impulsivity before and after treatment. 41 articles selected were included for pharmacological treatment. 24 articles were found for psychotherapeutic management and one randomized study of transcranial magnetic stimulation. Based on this review, we must focus on psychotherapy in BPD, particularly the schema therapy, dialectical behavioral therapy, psychoeducation, system training of emotional predictability and problem solving and psychotherapy using mentalisation. The use of neuroleptics and mood stabilizers appears to be more effective than antidepressants. Another approach, such as transcranial magnetic stimulation, may prove useful in the near future if this technique is studied further.

Change in core symptoms of borderline personality disorder by tDCS: A pilot study

Borderline personality disorder (BPD) recognizes several psychopathological dimensions related to prefrontal cortex impairments. Transcranial Direct Current Stimulation (tDCS) targeting the right prefrontal dorsolateral cortex (DLPFC) positively influence cognitive functions related to impulsivity in healthy subjects. A randomized double-blind study was designed to investigate whether tDCS could modulate core dimensions (impulsivity, aggression, affective dysregulation) of BPD. Also effects on decision making process and substances craving was assessed. Patients were randomized to receive active-tDCS at 2 mA versus sham-tDCS, once a day for 15 sessions. Anode was placed on the right DLPFC (F4), cathode on the left DLPFC (F3). Impulsivity and aggression measures were significantly reduced only in patients treated with active-tDCS. Decision-making process was marginally influenced by the active current. Craving intensity was reduced only in the active-tDCS sample. Both groups showed improvements in the affective dysregulation dimension and anxious and depressive symptoms. The application of bilateral tDCS targeting right DLPFC with anodal stimulation seems to improve core dimensions of BPD (mainly impulsivity and aggression) probably by restoring prefrontal activity. tDCS might be a potential tool for preventing self-harming behaviors.

Developments in diagnosis and treatment of people with borderline personality disorder

PURPOSE OF REVIEW

Borderline personality disorder (BPD) attracts significant attention from clinicians and researchers alike. Despite increased recognition and willingness to diagnose BPD, most effective treatment approaches remain inaccessible to most. We consider recent developments in the diagnosis and treatment of BPD.

RECENT FINDINGS

A literature search of EMBASE and PsychINFO, using the search terms 'borderline personality disorder,' 'diagnosis' and 'treatment' for publications since October 2018, yielded over 300 articles and reviews. The literature highlights the increasing awareness of the diagnostic complexity of BPD as well as the emerging significance of 'common factors' and stepped care approaches for managing and treating the disorder.

SUMMARY

Clinical practice is evolving to embrace more holistic diagnostic approaches, generalist treatment frameworks and stepped-care models that can be tailored to fit individual needs and service resources. The new frontiers in this field include expansion of timely treatment options, improved knowledge regarding the expression and management of BPD in men, adolescents and the elderly, and bridging cultural divides to create a worldwide population approach.

Repetitive Transcranial Magnetic Stimulation in the Treatment of a Difficult to Treat Condition, Borderline Personality Disorder

BACKGROUND

Borderline personality disorder (BPD) is a serious mental disorder characterized by a pervasive pattern of instability in affect regulation and interpersonal relationships, poor self-image and behavioral control, self-injurious behavior, suicidality, and other high-risk behaviors. It is also characterized by a high mortality rate by suicide.

METHODS

The published literature on repetitive transcranial magnetic stimulation (TMS), theta-burst stimulation (TBS), and deep TMS in the treatment of BPD were reviewed.

RESULTS

Four clinical studies (2 randomized trials and 2 case studies) with limited sample sizes found that TMS and TBS were safe and potentially effective in the reduction of symptoms of BPD.

CONCLUSIONS

Given the limited clinical evidence for efficacy on the basis of the results of these studies, future controlled studies involving larger samples and optimal stimulus parameters should be designed to confirm the short-term and long-term safety and efficacy of repetitive TMS and TBS in the treatment of BPD.

Transcranial magnetic stimulation for the treatment of anxiety disorder

Anxiety is currently one of the main mood changes and can impair the quality of life of the individual when associated with other neurological or psychiatric disorders. Neuromodulation has been highlighted as a form of treatment of several pathologies, including those involving anxiety symptoms. Among the neuromodulatory options with the potential to improve mood changes, we highlight repetitive transcranial magnetic stimulation (rTMS). rTMS is a viable therapeutical option for neuropsychiatric dysfunctions of high prevalence and is important for the understanding of pathological and neuropsychological adaptation processes. Even with this potential, and high relevance of intervention, we observe the scarcity of literature that covers this subject. The objective of this study was to carry out a survey of the current literature, using scientific databases for the last five years. We found 32 studies reporting the effects of rTMS on anxiety, 7 on anxiety disorders and 25 on anxiety symptoms as comorbidities of neurological or psychiatric disorders. This survey suggests the need for further studies using TMS for anxiety in order to seek strategies that minimize these anxiety effects on the quality of life of the victims of this disorder.

Repetitive Transcranial Magnetic Stimulation (rTMS) Modulates Hippocampal Structural Synaptic Plasticity in Rats

Repetitive transcranial magnetic stimulation (rTMS) was shown to have therapeutic potential for some neurological and psychiatric disorders. Previous studies reported that low-frequency rTMS (</=1 Hz) affected synaptic plasticity in rats, however, there were few investigations to examine the possible effects of rTMS on structural synaptic plasticity changes in rats, which included the effects on synaptic morphology in the hippocampus, synaptic protein markers and Ca(2+)/calmodulin-dependent protein II (CaMKII). Sprague-Dawley rats were subject to 500 pulses of 0.5 Hz rTMS for 15 days, or sham stimulation. After last stimulation, transmission electron microscope (TEM) and real-time PCR were used to determine the effects of rTMS on synaptic plasticity. Results showed that rTMS could cause the change of structural synaptic plasticity, increase the expression of synaptic protein markers: synaptophysin (SYN) and increase the expression of CaMKII, relative to normal rats. suggesting a modulatory effect of chronic rTMS on synaptic plasticity that may be attributed to the increased expression of CaMKII in rats.