Heightened Salience of Anger and Aggression in Female Adolescents With Borderline Personality Disorder-A Script-Based fMRI Study

Etiopathogenesis in the Development of Borderline Personality Characteristics in Children and Adolescents

The validity and clinical significance of the characteristics of borderline personality disorder (BPD) in adolescents are increasingly being recognized. The persistence of BPD characteristics in adolescence is high and is associated with negative interpersonal, academic, professional, and financial outcomes. In the literature, BPD characteristics observed in children and adolescents are explained with psychodynamic theories, developmental models, and evolutionary approaches. Emotional dysregulation, interpersonal dysfunction, impulsivity, and self-harming behavior, negative life events, temperament characteristics, neuropsychological dysfunctions, neuroanatomical, genetic, hormonal, and immunological factors may play a role in BPD etiopathogenesis. This review aims to address different approaches and relevant factors for the development of BPD. The articles published between 1968-2021 in the PubMed database were reviewed, and prominent studies were selected for evaluation. The importance of invalidating environment, epistemic freezing and hypermentalization, complex or attachment trauma is emphasized in psychodynamic and developmental literature. In the evolutionary approach, on the other hand, romantic relationships and the onset of reproduction are emphasized as the reason for the emergence of symptoms during adolescence, and it is argued that BPD is related to the rapid life history strategy. It is stated that a decrease in volume in the orbitofrontal cortex and anterior cingulate cortex, which are involved in top-down emotional processing, and an increase in the activity of thalamus and hippocampus regions, which are involved in bottom-up emotional processing are observed in adolescents with BPD characteristics when compared to healthy controls. It is thought that the increase in activation in the superior temporal gyrus and precuneus observed in adolescents with BPD features is a neural indicator of hypermentalization, and the increase in activation in the insula is a neural indicator of social pain. It has been reported that the decrease in resting heart rate and the increase in heart rate variability observed in adolescents with BPD symptoms are associated with the activation of the parasympathetic system. BPD in adolescents is a disorder that challenges clinicians in terms of diagnosis, differential diagnosis, and treatment. It is crucial to evaluate the factors related to etiopathogenesis in BPD in a multifaceted and detailed manner. Keywords: Borderline Personality Disorder, Difficulty in Emotion Regulation, Mentalization, Trauma, Self-harming Behavior, Temperamental Characteristics.

Modulation of Trust in Borderline Personality Disorder by Script-Based Imaginal Exposure to Betrayal

Interpersonal and trust-related difficulties are central features of borderline personality disorder (BPD). In this study, we applied script-driven betrayal imagery to evoke mistrustful behavior in a social reinforcement learning task. In 21 BPD and 20 healthy control (HC) participants, we compared this approach to the standard confederate paradigm used in research studies. The script-driven imagery evoked a transient increase in negative affect and also decreased trusting behavior to a similar degree in both groups. Across conditions, we also replicated previously reported between-group differences in negative affect (increased in BPD) and task behavior (more sensitive to social cues in BPD). These results support the validity of script-driven imagery as an alternative social task stimulus. This script-driven imagery approach is appealing for clinical research studies on reinforcement learning because it eliminates deception, scales easily, and evokes disorder-specific states of social difficulty.

Brain functional abnormality in drug treated and drug naïve adolescents with borderline personality disorder: Evidence for default mode network dysfunction

BACKGROUND

Patients with borderline personality disorder (BPD) have been found to show functional brain abnormality, including in the medial frontal cortex and other areas of the default mode network (DMN). The current study aimed to examine activations and de-activations in drug treated and medication-free female adolescents with the disorder.

METHODS

39 DSM-5 adolescent female patients with BPD without psychiatric comorbidity and 31 matched healthy female adolescents underwent fMRI during the performance of 1-back and 2-back versions of the n-back working memory task. Linear models were used to obtain maps of within-group activations and de-activations and areas of differences between the groups.

RESULTS

On corrected whole-brain analysis, the BPD patients showed failure to de-activate a region of the medial frontal cortex in the 2-back > 1-back comparison. The 30 never-medicated patients additionally showed a failure to de-activate the right hippocampus in the 2-back versus baseline contrast.

CONCLUSIONS

Evidence of DMN dysfunction was observed in adolescent patients with BPD. Because the relevant medial frontal and hippocampal changes were seen in unmedicated young patients without comorbidity, they might be considered intrinsic to the disorder.

Altered brain activity and childhood trauma in Chinese adolescents with borderline personality disorder

BACKGROUND

Childhood trauma may cause borderline personality disorder (BPD). The aim of this study was to assess functional alteration and its association with childhood trauma in Chinese adolescents with BPD.

METHODS

A total of 187 adolescents with BPD aged 12-17 years and 207 age and gender- matched healthy controls (HCs) were enrolled into this study. The sample consisted of 50 adolescents with BPD and 21 HCs underwent brain resting-state functional magnetic resonance imaging (rs-fMRI). The rs-fMRI data was analyzed for both neural activity as indicated by amplitude of low-frequency fluctuation (ALFF) and seed-based functional connectivity (FC). Clinical assessment for childhood trauma, impulsivity, and depression was also performed. Correlative analysis of functional alterations with childhood trauma assessment were performed.

RESULTS

Adolescents with BPD had significantly higher rate of all assessed childhood trauma than the HC group (P < 0.001). Most adolescents with BPD (61.5 %) had emotional neglect, which was the most commonly seen type of childhood trauma. Compared with HCs, adolescents with BPD showed decreased ALFF in the cortical regions including the left superior frontal gyrus and right middle occipital gyrus, and default mode network (DMN) regions including the left angular gyrus and medial superior frontal gyrus. Adolescents with BPD also showed enhanced ALFF in the limbic system (left hippocampus, insula, thalamus) (P < 0.05, FWE correction, cluster size ≥100). There were significant correlations between the insula ALFF and childhood trauma assessment for emotional neglect, physical abuse and physical neglect (P < 0.01). Moreover, adolescents with BPD showed increased FC between the left insula and right cortical regions (voxel P < 0.001, cluster P < 0.05, FWE correction).

LIMITATIONS

The sample size was small. This cohort had patients with more severe BPD symptoms and some had comorbidities such as anxiety and obsessive-compulsive disorder.

CONCLUSIONS

There were alterations of brain activity as indicated by ALFF in the limbic - cortical circuit and DMN regions in adolescents with BPD and the activity in the left insula was correlated with emotional neglect. In addition, the FC between the left insula and the limbic - prefrontal circuit was enhanced. These results implicate that the functional alterations of insula may serve as a potential neuroimaging biomarker for adolescents with BPD who suffered from childhood trauma.

Altered regional homogeneity and its association with cognitive function in adolescents with borderline personality disorder

BACKGROUND

Adolescents with borderline personality disorder often have cognitive impairment, but the underlying mechanism for this is not clear. This study was aimed at assessing alterations in regional homogeneity using resting-state functional MRI (fMRI) in adolescents with borderline personality disorder, and evaluating the associations between regional homogeneity and cognitive testing scores.

METHODS

We enrolled 50 adolescents with borderline personality disorder (age 12-17 years) and 21 age- and sex-matched healthy controls. We performed regional homogeneity and seed-based functional connectivity analysis for both groups. We also performed correlative analysis for regional homogeneity and cognitive testing scores.

RESULTS

Compared with healthy controls, adolescents with borderline personality disorder had reduced regional homogeneity values in the frontal cortex (including the left inferior orbitofrontal cortex and the bilateral superior frontal cortex) as well as in the left precuneus in the default mode network. Adolescents with borderline personality disorder also had higher regional homogeneity values in several cortical regions: the right middle temporal gyrus, the right cuneus, the right precentral gyrus and the left middle occipital gyrus. Regional homogeneity values in the left middle occipital gyrus, left inferior orbitofrontal cortex and right superior frontal gyrus were associated with cognitive testing scores in adolescents with borderline personality disorder. We also found increased functional connectivity between the left middle occipital gyrus and right superior frontal gyrus in adolescents with borderline personality disorder.

LIMITATIONS

This study had a modest sample size, with a possible case selection bias for patients with more severe illness. This cohort also included patients with comorbidities or taking psychotropic medications, which may have confounded study results.

CONCLUSION

Alterations in regional homogeneity and functional connectivity in brain regions that involve the limbic-cortical circuit could be neural correlates for cognitive impairment in adolescents with borderline personality disorder.

Brain responses in aggression-prone individuals: A systematic review and meta-analysis of functional magnetic resonance imaging (fMRI) studies of anger- and aggression-eliciting tasks

Reactive aggression in response to perceived threat or provocation is part of humans' adaptive behavioral repertoire. However, high levels of aggression can lead to the violation of social and legal norms. Understanding brain function in individuals with high levels of aggression as they process anger- and aggression-eliciting stimuli is critical for refining explanatory models of aggression and thereby improving interventions. Three neurobiological models of reactive aggression - the limbic hyperactivity, prefrontal hypoactivity, and dysregulated limbic-prefrontal connectivity models - have been proposed. However, these models are based on neuroimaging studies involving mainly non-aggressive individuals, leaving it unclear which model best describes brain function in those with a history of aggression. We conducted a systematic literature search (PubMed and Psycinfo) and Multilevel Kernel Density meta-analysis (MKDA) of nine functional magnetic resonance imaging (fMRI) studies (eight included in the between-group analysis [i.e., aggression vs. control groups], five in the within-group analysis). Studies examined brain responses to tasks putatively eliciting anger and aggression in individuals with a history of aggression alone and relative to controls. Individuals with a history of aggression exhibited greater activity in the superior temporal gyrus and in regions comprising the cognitive control and default mode networks (right posterior cingulate cortex, precentral gyrus, precuneus, right inferior frontal gyrus) during reactive aggression relative to baseline conditions. Compared to controls, individuals with a history of aggression exhibited increased activity in limbic regions (left hippocampus, left amygdala, left parahippocampal gyrus) and temporal regions (superior, middle, inferior temporal gyrus), and reduced activity in occipital regions (left occipital cortex, left calcarine cortex). These findings lend support to the limbic hyperactivity model in individuals with a history of aggression, and further indicate altered temporal and occipital activity in anger- and aggression-eliciting conditions involving face and speech processing.

Identifying Disease-Specific Neural Reactivity to Psychosocial Stress in Borderline Personality Disorder

BACKGROUND

Patients with borderline personality disorder (BPD) typically present emotion dysregulation (ED) when faced with adversity. However, it is argued that altered stress response may be more influenced by ED than BPD-specific traits. Here, we investigated this issue with functional magnetic resonance imaging using another ED condition as clinical control, i.e., bipolar disorder (BD), and controlling for ED traits.

METHODS

We recruited 17 patients with BD, 24 patients with BPD, and 32 healthy control (HC) subjects. We adapted a functional magnetic resonance imaging-compatible psychosocial stressor task (Montreal Imaging Stress Task) in which participants are placed under time pressure when performing mental calculations and then receive immediate performance feedback (positive, negative, and neutral). ED traits were measured via self-report questionnaires targeting cognitive emotion dysregulation, affective lability, and trait anger and anxiety.

RESULTS

Relative to patients with BD and HC subjects, patients with BPD exhibited overactive corticolimbic reactivity across all conditions, particularly in self-monitoring and emotion regulation regions such as the orbitofrontal cortex and anterior insula, even when controlling for ED. Conversely, patients with BD exhibited hypoactive corticolimbic reactivity to all feedback conditions compared with patients with BPD and HC subjects, even after controlling for ED. HC subjects exhibited significantly lower amygdala/hippocampus activity compared with both clinical groups, although this did not survive when controlling for ED.

CONCLUSIONS

This study provides new insight into BPD-specific neural stress responding, suggesting hyperactive self- and emotion-regulatory neural psychosocial stress responding, independent of ED traits. The findings also highlight the importance of considering BPD as a diagnostic profile distinguishable from other ED disorder clinical groups.

Aberrant Structural Connectivity of the Triple Network System in Borderline Personality Disorder Is Associated with Behavioral Dysregulation

Background: Core symptoms of Borderline Personality Disorder (BPD) are associated to aberrant connectivity of the triple network system (salience network [SN], default mode network [DMN], executive control network [ECN]). While functional abnormalities are widely reported, structural connectivity (SC) and anatomical changes have not yet been investigated. Here, we explored the triple network’s SC, structure, and its association with BPD clinical features. Methods: A total of 60 BPD and 26 healthy controls (HC) underwent a multidomain neuropsychological and multimodal MRI (diffusion- and T1-weighted imaging) assessment. Metrics (fractional anisotropy [FA], mean diffusivity [MD], cortical thickness) were extracted from SN, DMN, ECN (triple network), and visual network (control network) using established atlases. Multivariate general linear models were conducted to assess group differences in metrics and associations with clinical features. Results: Patients showed increased MD in the anterior SN, dorsal DMN, and right ECN compared to HC. Diffusivity increases were more pronounced in patients with higher behavioral dysregulation, i.e., suicidal attempting, self-harm, and aggressiveness. No differences were detected in network structure. Conclusions: These results indicate that the triple network system is impaired in BPD at the microstructural level. The preferential involvement of anterior and right-lateralized subsystems and their clinical association suggests that these abnormalities could contribute to behavioral dysregulation.

Structural and functional biomarkers of the insula subregions predict sex differences in aggression subscales

Aggression is a common and complex social behavior that is associated with violence and mental diseases. Although sex differences were observed in aggression, the neural mechanism for the effect of sex on aggression behaviors remains unclear, especially in specific subscales of aggression. In this study, we investigated the effects of sex on aggression subscales, gray matter volume (GMV), and functional connectivity (FC) of each insula subregion as well as the correlation of aggression subscales with GMV and FC. This study found that sex significantly influenced (a) physical aggression, anger, and hostility; (b) the GMV of all insula subregions; and (c) the FC of the dorsal agranular insula (dIa), dorsal dysgranular insula (dId), and ventral dysgranular and granular insula (vId_vIg). Additionally, mediation analysis revealed that the GMV of bilateral dIa mediates the association between sex and physical aggression, and left dId–left medial orbital superior frontal gyrus FC mediates the relationship between sex and anger. These findings revealed the neural mechanism underlying the sex differences in aggression subscales and the important role of the insula in aggression differences between males and females. This finding could potentially explain sexual dimorphism in neuropsychiatric disorders and improve dysregulated aggressive behavior.

Aggression in borderline personality disorder: A systematic review of neuroimaging studies

Aggressive behaviors are prevalent among patients with Borderline Personality Disorder (BPD). Neuroimaging studies have linked aggression in BPD patients to neurochemical, structural, functional, and metabolic alterations in various brain regions, especially in frontal-limbic areas. This systematic review summarizes current neuroimaging results on aggression among BPD patients and provides an overview of relevant brain mechanisms. A systematic search of PubMed and Web of Science databases, in addition to manual check of references, identified thirty-two eligible articles, including two magnetic resonance spectrum (MRS), thirteen structural magnetic resonance imaging (sMRI), six functional magnetic resonance imaging (fMRI), and eleven positron emission tomography (PET) studies. The reviewed studies have highlighted the abnormalities in prefrontal cortices and limbic structures including amygdala and hippocampus. Less studies have zoomed in the roles of parietal and temporal regions or taken a network perspective. Connectivity studies have shed light on the importance of the frontal-limbic interactions in regulating aggression. Conflicted findings might be attributed to disparity in controlling gender, anatomical subdivisions, and comorbidities, which shall be considered in future studies.

The borderline interpersonal-affective systems (BIAS) model: Extending understanding of the interpersonal context of borderline personality disorder

Prominent explanatory models for borderline personality disorder (BPD) are intrapersonal in nature and hold that it is an emotional disorder. However, the empirical support for emotional models of BPD is mixed. Refinements to BPD explanatory models are needed to increase the precision with which BPD can be understood and treated. Drawing on existing theoretical and empirical research in BPD, this manuscript presents the Borderline Interpersonal-Affective Systems (BIAS) model. The BIAS model purports that harmful early life relationships and subsequent conflictual relationships lead individuals with BPD to develop a sensitivity to interpersonal threat in the form of attentional and appraisal biases. Individuals with BPD are posited to 1) experience heightened emotional reactivity specifically to perceived interpersonal threat and 2) engage in destructive behaviors both to regulate increasing emotion and to meet interpersonal needs. We review the empirical support for each component of the BIAS model, along with the role of the cognitions, emotions, and behaviors of significant others in influencing BIAS model processes in individuals with BPD over time. The BIAS model highlights a novel way of understanding and integrating interpersonal and emotional components of the disorder. Key directives for future research and clinical implications are discussed.

Aberrant functional connectivity profiles of brain regions associated with salience and reward processing in female patients with borderline personality disorder

Recent resting-state functional connectivity studies have shown significant group differences in several networks between patients suffering from borderline personality disorder (BPD) and healthy controls. However, reliable and consistent findings have not been reported yet. Several methodological factors might be responsible for the discrepant findings, including the heterogeneity of patient samples in terms of symptom severity. In the current study, we combined investigations of the whole-brain resting-state functional connectivity patterns of BPD patients with seed-based connectivity measures and then computed the correlation of connectivity measures with borderline symptom severity. Correlation-based connectivity analysis was performed on resting-state functional magnetic resonance imaging (fMRI) data from 26 female BPD patients and 26 healthy controls. Increased intrinsic connectivity was found in clusters involving part of the caudate nucleus and the left insula in the patient group, indicating greater integration of each region. Further seed-based connectivity analyses revealed that with the caudate seed, the patient data exhibited an increased resting-state functional connectivity in the bilateral ventral striatum and the midline prefrontal regions extending to the ACC, a network associated with reward processing. The left insula seed showed significantly increased connectivity with the bilateral fronto-orbital/insula, the inferior parietal lobule and the mid-cingulate cortex, a network involved in attention and salience encoding, in the patient population. Moreover, symptom severity, as assessed with the BSL-95 outside the scanner, was negatively correlated with the coupling of the insula and the striatum in the BPD group. Overall, an increased functional connectivity within two large-scale circuitries underlying reward and salience processing was evident in patients, as compared to healthy participants. When correlated with borderline symptom severity, a reduced connectivity between key regions belonging to the reward system and salience network was observed in the patients. These findings may be helpful for facilitating further understanding of the potential mechanisms underlying the BPD pathophysiology and thereby delineate potential treatment targets.

Emotional Dysregulation in Children and Adolescents With Psychiatric Disorders. A Narrative Review

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.

The vicious circle of social exclusion and psychopathology: a systematic review of experimental ostracism research in psychiatric disorders

Social exclusion (ostracism) is a major psychosocial factor contributing to the development and persistence of psychiatric disorders and is also related to their social stigma. However, its specific role in different disorders is not evident, and comprehensive social psychology research on ostracism has rather focused on healthy individuals and less on psychiatric patients. Here, we systematically review experimental studies investigating psychological and physiological reactions to ostracism in different responses of psychiatric disorders. Moreover, we propose a theoretical model of the interplay between psychiatric symptoms and ostracism. A systematic MEDLINE and PsycINFO search was conducted including 52 relevant studies in various disorders (some of which evaluated more than one disorder): borderline personality disorder (21 studies); major depressive disorder (11 studies); anxiety (7 studies); autism spectrum disorder (6 studies); schizophrenia (6 studies); substance use disorders (4 studies); and eating disorders (2 studies). Psychological and physiological effects of ostracism were assessed with various experimental paradigms: e.g., virtual real-time interactions (Cyberball), social feedback and imagined scenarios. We critically review the main results of these studies and propose the overall concept of a vicious cycle where psychiatric symptoms increase the chance of being ostracized, and ostracism consolidates or even aggravates psychopathology. However, the specificity and stability of reactions to ostracism, their neurobiological underpinnings, determinants, and moderators (e.g., attachment style, childhood trauma, and rejection sensitivity) remain elusive.

An Integrative Way for Studying Neural Basis of Basic Emotions With fMRI

How emotions are represented in the nervous system is a crucial unsolved problem in the affective neuroscience. Many studies are striving to find the localization of basic emotions in the brain but failed. Thus, many psychologists suspect the specific neural loci for basic emotions, but instead, some proposed that there are specific neural structures for the core affects, such as arousal and hedonic value. The reason for this widespread difference might be that basic emotions used previously can be further divided into more “basic” emotions. Here we review brain imaging data and neuropsychological data, and try to address this question with an integrative model. In this model, we argue that basic emotions are not contrary to the dimensional studies of emotions (core affects). We propose that basic emotion should locate on the axis in the dimensions of emotion, and only represent one typical core affect (arousal or valence). Therefore, we propose four basic emotions: joy-on positive axis of hedonic dimension, sadness-on negative axis of hedonic dimension, fear, and anger-on the top of vertical dimensions. This new model about basic emotions and construction model of emotions is promising to improve and reformulate neurobiological models of basic emotions.

Effects of Childhood Maltreatment on Social Cognition and Brain Functional Connectivity in Borderline Personality Disorder Patients

Borderline personality disorder (BPD) is a chronic condition characterized by high levels of impulsivity, affective instability, and difficulty to establish and manage interpersonal relationships. However, little is known about its etiology and neurobiological substrates. In our study, we wanted to investigate the influence of child abuse in the psychopathology of BPD by means of social cognitive paradigms [the Movie for the Assessment of Social Cognition (MASC) and the reading the mind in the eyes test (RMET)], and resting state functional magnetic resonance imaging (rs-fMRI). For this, we recruited 33 participants, 18 BPD patients, and 15 controls. High levels of self-reported childhood maltreatment were reported by BPD patients. For the sexual abuse subdimension, there were no differences between the BPD and the control groups, but there was a negative correlation between MASC scores and total childhood maltreatment levels, as well as between physical abuse, physical negligence, and MASC. Both groups showed that the higher the level of childhood maltreatment, the lower the performance on the MASC social cognitive test. Further, in the BPD group, there was hypoconnectivity between the structures responsible for emotion regulation and social cognitive responses that have been described as part of the frontolimbic circuitry (i.e., amygdala). Differential levels of connectivity, associated with different types and levels of abuse were also observed.

Treatment Effects following Residential Dialectical Behavior Therapy for Adolescents with Borderline Personality Disorder

Dialectical behavior therapy (DBT) is an empirically supported treatment for borderline personality disorder (BPD) in adults, however fewer studies have examined outcomes in adolescents. This study tested the effectiveness of an intensive 1-month, residential DBT treatment for adolescent girls meeting criteria for BPD. Additionally, given well-established associations between BPD symptoms and childhood abuse, the impact of abuse on treatment outcomes was assessed. Participants were female youth (n = 53) aged 13-20 years (M = 17.00, SD = 1.89) completing a 1-month residential DBT program. At pre-treatment, participants were administered a diagnostic interview and self-report measures assessing BPD, depression, and anxiety symptom severity. Following one month of treatment, participants were re-administered the self-report instruments. Results showed significant pre- to post-treatment reductions in both BPD and depression symptom severity with large effects. However, there was no significant change in general anxious distress or anxious arousal over time. The experience of childhood abuse (sexual, physical, or both) was tested as moderator of treatment effectiveness. Although experiencing multiple types of abuse was related to symptom severity, abuse did not moderate the effects of treatment. Collectively, results indicate that a 1-month residential DBT treatment with adolescents may result in reductions in BPD and depression severity but is less effective for anxiety. Moreover, while youth reporting abuse benefitted from treatment, they were less likely to achieve a clinically significant reduction in symptoms.