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Levine SM, Merz K, Keeser D, Kunz JI, Barton BB, Reinhard MA, Jobst A, Padberg F, Neukel C, Herpertz SC, Bertsch K, Musil R. Altered amygdalar emotion space in borderline personality disorder normalizes following dialectical behaviour therapy. J Psychiatry Neurosci 2023; 48:E431-E438. [PMID: 37935476 PMCID: PMC10635707 DOI: 10.1503/jpn.230085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/24/2023] [Accepted: 09/05/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Borderline personality disorder (BPD) is a mental health condition characterized by an inability to regulate emotions or accurately process the emotional states of others. Previous neuroimaging studies using classical univariate analyses have tied such emotion dysregulation to aberrant activity levels in the amygdala of patients with BPD. However, multivariate analyses have not yet been used to investigate how representational spaces of emotion information may be systematically altered in patients with BPD. METHODS Patients with BPD performed an emotional face matching task while undergoing MRI before and after a 10-week inpatient program of dialectical behavioural therapy. Representational similarity analysis (RSA) was applied to activity patterns (evoked by angry, fearful, neutral and surprised faces) in the amygdala and temporo-occipital fusiform gyrus of patients with BPD and in the amygdala of healthy controls. RESULTS We recruited 15 patients with BPD (8 females, 6 males, 1 transgender male) to participate in the study, and we obtained a neuroimaging data set for 25 healthy controls for a comparative analysis. The RSA of the amygdala revealed a negative bias in the underlying affective space (in that activity patterns evoked by angry, fearful and neutral faces were more similar to each other than to patterns evoked by surprised faces), which normalized after therapy. This bias-to-normalization effect was present neither in activity patterns of the temporo-occipital fusiform gyrus of patients nor in amygdalar activity patterns of healthy controls. LIMITATIONS Larger samples and additional questionnaires would help to better characterize the association between specific aspects of therapy and changes in the neural representational space. CONCLUSION Our findings suggest a more refined role for the amygdala in the pathological processing of perceived emotions and may provide new diagnostic and prognostic imaging-based markers of emotion dysregulation and personality disorders.Clinical trial registration: DRKS00019821, German Clinical Trials Register (Deutsches Register Klinischer Studien).
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Affiliation(s)
- Seth M Levine
- From the Department of Psychology, LMU Munich, Munich, Germany (Levine, Bertsch); the NeuroImaging Core Unit Munich (NICUM), University Hospital, LMU Munich, Munich, Germany (Levine, Merz, Keeser, Bertsch); the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany (Merz, Keeser, Kunz, Barton, Reinhard, Jobst, Padberg, Musil); the Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany (Neukel, Herpertz, Bertsch); and the German Center for Mental Health (DZPG), Munich, Germany (Padberg, Bertsch)
| | - Katharina Merz
- From the Department of Psychology, LMU Munich, Munich, Germany (Levine, Bertsch); the NeuroImaging Core Unit Munich (NICUM), University Hospital, LMU Munich, Munich, Germany (Levine, Merz, Keeser, Bertsch); the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany (Merz, Keeser, Kunz, Barton, Reinhard, Jobst, Padberg, Musil); the Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany (Neukel, Herpertz, Bertsch); and the German Center for Mental Health (DZPG), Munich, Germany (Padberg, Bertsch)
| | - Daniel Keeser
- From the Department of Psychology, LMU Munich, Munich, Germany (Levine, Bertsch); the NeuroImaging Core Unit Munich (NICUM), University Hospital, LMU Munich, Munich, Germany (Levine, Merz, Keeser, Bertsch); the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany (Merz, Keeser, Kunz, Barton, Reinhard, Jobst, Padberg, Musil); the Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany (Neukel, Herpertz, Bertsch); and the German Center for Mental Health (DZPG), Munich, Germany (Padberg, Bertsch)
| | - Julia I Kunz
- From the Department of Psychology, LMU Munich, Munich, Germany (Levine, Bertsch); the NeuroImaging Core Unit Munich (NICUM), University Hospital, LMU Munich, Munich, Germany (Levine, Merz, Keeser, Bertsch); the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany (Merz, Keeser, Kunz, Barton, Reinhard, Jobst, Padberg, Musil); the Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany (Neukel, Herpertz, Bertsch); and the German Center for Mental Health (DZPG), Munich, Germany (Padberg, Bertsch)
| | - Barbara B Barton
- From the Department of Psychology, LMU Munich, Munich, Germany (Levine, Bertsch); the NeuroImaging Core Unit Munich (NICUM), University Hospital, LMU Munich, Munich, Germany (Levine, Merz, Keeser, Bertsch); the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany (Merz, Keeser, Kunz, Barton, Reinhard, Jobst, Padberg, Musil); the Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany (Neukel, Herpertz, Bertsch); and the German Center for Mental Health (DZPG), Munich, Germany (Padberg, Bertsch)
| | - Matthias A Reinhard
- From the Department of Psychology, LMU Munich, Munich, Germany (Levine, Bertsch); the NeuroImaging Core Unit Munich (NICUM), University Hospital, LMU Munich, Munich, Germany (Levine, Merz, Keeser, Bertsch); the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany (Merz, Keeser, Kunz, Barton, Reinhard, Jobst, Padberg, Musil); the Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany (Neukel, Herpertz, Bertsch); and the German Center for Mental Health (DZPG), Munich, Germany (Padberg, Bertsch)
| | - Andrea Jobst
- From the Department of Psychology, LMU Munich, Munich, Germany (Levine, Bertsch); the NeuroImaging Core Unit Munich (NICUM), University Hospital, LMU Munich, Munich, Germany (Levine, Merz, Keeser, Bertsch); the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany (Merz, Keeser, Kunz, Barton, Reinhard, Jobst, Padberg, Musil); the Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany (Neukel, Herpertz, Bertsch); and the German Center for Mental Health (DZPG), Munich, Germany (Padberg, Bertsch)
| | - Frank Padberg
- From the Department of Psychology, LMU Munich, Munich, Germany (Levine, Bertsch); the NeuroImaging Core Unit Munich (NICUM), University Hospital, LMU Munich, Munich, Germany (Levine, Merz, Keeser, Bertsch); the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany (Merz, Keeser, Kunz, Barton, Reinhard, Jobst, Padberg, Musil); the Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany (Neukel, Herpertz, Bertsch); and the German Center for Mental Health (DZPG), Munich, Germany (Padberg, Bertsch)
| | - Corinne Neukel
- From the Department of Psychology, LMU Munich, Munich, Germany (Levine, Bertsch); the NeuroImaging Core Unit Munich (NICUM), University Hospital, LMU Munich, Munich, Germany (Levine, Merz, Keeser, Bertsch); the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany (Merz, Keeser, Kunz, Barton, Reinhard, Jobst, Padberg, Musil); the Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany (Neukel, Herpertz, Bertsch); and the German Center for Mental Health (DZPG), Munich, Germany (Padberg, Bertsch)
| | - Sabine C Herpertz
- From the Department of Psychology, LMU Munich, Munich, Germany (Levine, Bertsch); the NeuroImaging Core Unit Munich (NICUM), University Hospital, LMU Munich, Munich, Germany (Levine, Merz, Keeser, Bertsch); the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany (Merz, Keeser, Kunz, Barton, Reinhard, Jobst, Padberg, Musil); the Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany (Neukel, Herpertz, Bertsch); and the German Center for Mental Health (DZPG), Munich, Germany (Padberg, Bertsch)
| | - Katja Bertsch
- From the Department of Psychology, LMU Munich, Munich, Germany (Levine, Bertsch); the NeuroImaging Core Unit Munich (NICUM), University Hospital, LMU Munich, Munich, Germany (Levine, Merz, Keeser, Bertsch); the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany (Merz, Keeser, Kunz, Barton, Reinhard, Jobst, Padberg, Musil); the Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany (Neukel, Herpertz, Bertsch); and the German Center for Mental Health (DZPG), Munich, Germany (Padberg, Bertsch)
| | - Richard Musil
- From the Department of Psychology, LMU Munich, Munich, Germany (Levine, Bertsch); the NeuroImaging Core Unit Munich (NICUM), University Hospital, LMU Munich, Munich, Germany (Levine, Merz, Keeser, Bertsch); the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany (Merz, Keeser, Kunz, Barton, Reinhard, Jobst, Padberg, Musil); the Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany (Neukel, Herpertz, Bertsch); and the German Center for Mental Health (DZPG), Munich, Germany (Padberg, Bertsch)
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Meyer K, Hindi Attar C, Fiebig J, Stamm T, Bassett TR, Bauer M, Dannlowski U, Ethofer T, Falkenberg I, Jansen A, Juckel G, Kircher T, Mulert C, Leicht G, Rau A, Rauh J, Ritter D, Ritter P, Trost S, Vogelbacher C, Walter H, Wolter S, Hautzinger M, Bermpohl F. Daring to Feel: Emotion-Focused Psychotherapy Increases Amygdala Activation and Connectivity in Euthymic Bipolar Disorder-A Randomized Controlled Trial. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2023; 8:750-759. [PMID: 36898634 DOI: 10.1016/j.bpsc.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/18/2023] [Accepted: 02/24/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND In bipolar disorder (BD), the alternation of extreme mood states indicates deficits in emotion processing, accompanied by aberrant neural function of the emotion network. The present study investigated the effects of an emotion-centered psychotherapeutic intervention on amygdala responsivity and connectivity during emotional face processing in BD. METHODS In a randomized controlled trial within the multicentric BipoLife project, euthymic patients with BD received one of two interventions over 6 months: an unstructured, emotion-focused intervention (FEST), where patients were guided to adequately perceive and label their emotions (n = 28), or a specific, structured, cognitive behavioral intervention (SEKT) (n = 31). Before and after interventions, functional magnetic resonance imaging was conducted while patients completed an emotional face-matching paradigm (final functional magnetic resonance imaging sample of patients completing both measurements: SEKT, n = 17; FEST, n = 17). Healthy control subjects (n = 32) were scanned twice after the same interval without receiving any intervention. Given the focus of FEST on emotion processing, we expected FEST to strengthen amygdala activation and connectivity. RESULTS Clinically, both interventions stabilized patients' euthymic states in terms of affective symptoms. At the neural level, FEST versus SEKT increased amygdala activation and amygdala-insula connectivity at postintervention relative to preintervention time point. In FEST, the increase in amygdala activation was associated with fewer depressive symptoms (r = 0.72) 6 months after intervention. CONCLUSIONS Enhanced activation and functional connectivity of the amygdala after FEST versus SEKT may represent a neural marker of improved emotion processing, supporting the FEST intervention as an effective tool in relapse prevention in patients with BD.
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Affiliation(s)
- Kristina Meyer
- Department of Psychiatry and Neurosciences, Charité Campus Mitte, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Catherine Hindi Attar
- Department of Psychiatry and Neurosciences, Charité Campus Mitte, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jana Fiebig
- Department of Psychiatry and Neurosciences, Charité Campus Mitte, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thomas Stamm
- Department of Psychiatry and Neurosciences, Charité Campus Mitte, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Department of Clinical Psychiatry and Psychotherapy, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Tyler R Bassett
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Michael Bauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Udo Dannlowski
- Institute for Translational Psychiatry, University of Münster, Münster, Germany
| | - Thomas Ethofer
- University Clinic for Psychiatry and Psychotherapy, Tübingen, Germany; Department of Biomedical Magnetic Resonance, University Clinic for Radiology Tübingen, Tübingen, Germany
| | - Irina Falkenberg
- Department of Psychiatry and Psychotherapy, University of Marburg, Germany
| | - Andreas Jansen
- Department of Psychiatry and Psychotherapy, University of Marburg, Germany; Core-Facility Brainimaging, Faculty of Medicine, University of Marburg, Marburg, Germany
| | - Georg Juckel
- Department of Psychiatry, Ruhr University Bochum, LWL University Hospital, Bochum, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy, University of Marburg, Germany
| | - Christoph Mulert
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Center for Psychiatry, Justus Liebig University, Giessen, Germany
| | - Gregor Leicht
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Rau
- University Clinic for Psychiatry and Psychotherapy, Tübingen, Germany
| | - Jonas Rauh
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dirk Ritter
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Philipp Ritter
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Sarah Trost
- Department of Psychiatry and Psychotherapy, Georg-August-University Göttingen, Göttingen, Germany; Department of Geriatric Psychiatry, Universitäre Altersmedizin FELIX PLATTER, Basel, Switzerland
| | - Christoph Vogelbacher
- Translational Clinical Psychology, Department of Psychology, Philipps-University Marburg, Marburg, Germany
| | - Henrik Walter
- Department of Psychiatry and Neurosciences, Charité Campus Mitte, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sarah Wolter
- Department of Psychiatry and Psychotherapy, Georg-August-University Göttingen, Göttingen, Germany; Department of Psychiatry and Psychotherapy, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Martin Hautzinger
- Department of Psychology, Clinical Psychology and Psychotherapy, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Felix Bermpohl
- Department of Psychiatry and Neurosciences, Charité Campus Mitte, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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