Dialectical behavior therapy alters emotion regulation and amygdala activity in patients with borderline personality disorder

Abstract

Objective Siever and Davis’ (1991) psychobiological framework of borderline personality disorder (BPD) identifies affective instability (AI) as a core dimension characterized by prolonged and intense emotional reactivity. Recently, deficient amygdala habituation, defined as a change in response to repeated relative to novel unpleasant pictures within a session, has emerged as a biological correlate of AI in BPD. Dialectical behavior therapy (DBT), an evidence-based treatment, targets AI by teaching emotion-regulation skills. This study tested the hypothesis that BPD patients would exhibit decreased amygdala activation and improved habituation, as well as improved emotion regulation with standard 12-month DBT. Methods Event-related fMRI was obtained pre- and post-12-months of standard-DBT in unmedicated BPD patients. Healthy controls (HCs) were studied as a benchmark for normal amygdala activity and change over time (n = 11 per diagnostic-group). During each scan, participants viewed an intermixed series of unpleasant, neutral and pleasant pictures presented twice (novel, repeat). Change in emotion regulation was measured with the Difficulty in Emotion Regulation (DERS) scale. Results fMRI results showed the predicted Group × Time interaction: compared with HCs, BPD patients exhibited decreased amygdala activation with treatment. This post-treatment amygdala reduction in BPD was observed for all three pictures types, but particularly marked in the left hemisphere and during repeated-emotional pictures. Emotion regulation measured with the DERS significantly improved with DBT in BPD patients. Improved amygdala habituation to repeated-unpleasant pictures in patients was associated with improved overall emotional regulation measured by the DERS (total score and emotion regulation strategy use subscale). Conclusion These findings have promising treatment implications and support the notion that DBT targets amygdala hyperactivity—part of the disturbed neural circuitry underlying emotional dysregulation in BPD. Future work includes examining how DBT-induced amygdala changes interact with frontal-lobe regions implicated in emotion regulation.

Behavioral and Neurobiological Correlates of Disturbed Emotion Processing in Borderline Personality Disorder

“…Although recent reports suggest significant effects of medication [35] and sex [41], still little is known about their effects and the influences of comorbid disorders or early adversity on neural correlates of disturbed emotion processing in BPD. From a clinical point of view, it is of interest that changes in amygdalar and prefrontal activations and functional coupling have been shown after dialectical behavioral therapy in patients with BPD [43, 50]. With regard to new experimental interventions, there is some evidence that the intranasal administration of the neuropeptide oxytocin may lead to a reduction of the amygdala and insula hyperresponsivity to negative emotional stimuli in patients with BPD [15, 51].…”

Neurobiological Mechanisms Mediating Emotion Dysregulation as Targets of Change in Borderline Personality Disorder

“…In this study, successful response was reached if at least two of three treatment goals, which were defined before starting psychotherapy, were reached according to the patient’s and therapist’s independent evaluations. Goodman et al [14] instructed a rather small but carefully selected group of unmedicated BPD patients to evaluate the valence of emotional scenes of the IAPS before and after a 12-month DBT program consisting of weekly skills and individual training sessions. After DBT, the patients reported significantly reduced emotion dysregulation in the Difficulties in Emotion Regulation Scale (DERS) and, in the fMRI, reduced amygdala activations to negative social cues was found, especially in the left hemisphere.…”

Amygdala and dlPFC abnormalities, with aberrant connectivity and habituation in response to emotional stimuli in females with BPD

“…Here we investigate the neural correlates of emotional processing in BPD and further examine altered habituation which has received limited attention 18 . We compared BPD and matched normal controls in a functional MRI (fMRI) block design task comparing emotion-inducing images specifically with neutral images.…”