Treatment of Aggression, Anger and Emotional Dysregulation in Borderline Personality Disorder
Condition: Borderline Personality Disorder
MeSH terms: Personality Disorders; Borderline Personality Disorder; Aggression
Study type: Interventional

Summary: 
      This study examines the effects of 12 months of dialectical behavior therapy (DBT) for
      subjects with borderline personality disorder on aggression, anger and emotional
      dysregulation. Treatment effects will be measured by changes in interview, self-report,
      psychophysiology testing and fMRI neuroimaging.
    

Detailed description: 
      Borderline Personality Disorder (BPD) is a disabling disorder characterized by poor affect
      regulation and poor impulse control. This often results in impaired interpersonal
      relationships and maladaptive behavioral patterns, including anger dyscontrol, aggression
      towards others and self-destructive behaviors. Evidence suggests that is a relatively common
      disorder, affecting 2% of the population 1. In addition, BPD patients have more frequent
      psychiatric hospitalizations, greater use of outpatient psychotherapy and more visits to the
      emergency room than individuals with any other psychiatric disorder 3, 4. Due to the
      heterogeneity of symptoms that fall under the DSM-IV definition of BPD, the most productive
      efforts to understand the underlying neurobiology of this disorder have employed a
      dimensional approach. This application focuses on the domain of affective instability and
      altered emotion regulation, believed by many to be at the core of the disorder 5.

      The emotional dysregulation of BPD appears to be a biological vulnerability. This
      vulnerability includes both increased emotional reactivity, as well as an impaired capacity
      to employ effortful control in the modulation of emotional reactions. The emotional
      reactivity is manifested by high sensitivity to emotional stimuli and heightened emotional
      intensity5 and may reflect limbic system over activity. The impairment in emotional
      modulation results in a slow return to the baseline emotional state and may reflect deficits
      in prefrontal regulatory regions. While data supporting this formulation are limited,
      self-report measures of responses to various emotional stimuli and more recently, objective,
      non-verbal physiological measures including startle eye blink modulation (SEM), have been
      used to test this theory.

      SEM is a well-established technique used to study the psychophysiology of emotion and has
      been shown to reflect amygdala activation6. Our research group has demonstrated exaggerated
      affective startle in BPD patients compared to healthy control subjects at later probe
      positions in response to words with emotionally negative valence, selected specifically to
      target emotions commonly unpleasant for BPD patients. Emerging neurobiological theories based
      on preliminary functional neuroimaging studies posit that BPD is a hyperarousal-dyscontrol
      syndrome 4, implicating dysfunction in amygdala activity coupled with weakening of prefrontal
      inhibitory control. Several neuroimaging studies from our research group have helped advance
      this idea7. Building on these exciting findings and the expertise available, this project
      uses a translational approach to study treatment effects on emotional regulation in BPD with
      SEM and prediction of treatment response with functional magnetic resonance imaging (fMRI).

      Dialectical Behavior Therapy is an empirically validated treatment approach emphasizing the
      role of emotion regulation in the treatment of suicidal and self-destructive behaviors in
      BPD8, 9. It has gained considerable popularity and is included as a component of the APA
      guidelines for treatment of BPD10. While this approach stresses skills and techniques for
      emotional regulation, and encourages cognitive control over maladaptive behavioral patterns,
      there have been neither neuroimaging nor psychophysiological studies of the effect of DBT on
      emotional processing in BPD, despite its proven efficacy. While neuroimaging and
      psychophysiological studies of a psychotherapeutic treatment have been done in major
      depression 11, 12 13, no such studies have been done in BPD. By examining changes in
      affective startle and baseline predictors of response with fMRI blood oxygenation level
      dependent (BOLD) activation patterns associated with DBT treatment, this project aims to
      better characterize the nature of emotional dysregulation in BPD, and identify features that
      predict a good response to DBT treatment. In addition, the project will explore the
      relationship between clinical improvement of BPD symptomatology with DBT treatment and
      changes in neurobiological measures by performing follow-up SEM after six and twelve months
      of DBT treatment. This approach will help elucidate the neuroanatomy of abnormal emotional
      processing in BPD and may help identify potential strategies for correcting these deficits.
    

Intervention name(s): Dialectical Behavior
Intervention type(s): Behavioral
Intervention description(s): Dialectical Behavior Therapy is an empirically validated treatment approach emphasizing the role of emotion regulation in the treatment of suicidal and self-destructive behaviors in BPD
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: affect; aggression; anger; behavior therapy; borderline personality disorder; MRI, functional