Abstract
Aggression is highly prevalent in borderline personality disorder (BPD). Previous studies have identified specific biobehavioral mechanisms underlying aggression in BPD, threat sensitivity being among them. We composited the mechanism-based anti-aggression psychotherapy (MAAP) in order to target these specific mechanisms, and MAAP was found to be superior to non-specific supportive psychotherapy (NSSP) in reducing aggressive behavior. In the present study, we investigated whether underlying brain mechanisms expected to be involved were affected by MAAP. To this end, n = 33 patients with BPD and overt aggressive behavior (n = 20 in MAAP, n = 13 in NSSP) and n = 25 healthy participants took part in a functional magnetic resonance imaging emotional face-matching task before and after treatment, or at a similar time interval for controls. Overt aggressive behavior was assessed using the overt aggression scale, modified. Results showed a decrease in amygdala activation in response to facial stimuli after MAAP, whereas an increase in amygdala activation was found after NSSP. Furthermore, in the MAAP group, connectivity between amygdala and dorsomedial prefrontal cortex increased from pre- to post-treatment compared to the NSSP group. Hence, the results suggest an impact of MAAP on brain mechanisms underlying the salience circuit in response to threat cues.
Highlights
Aggressive behavior, especially reactive aggression, is highly prevalent among female and male patients with borderline personality disorder (BPD) [1]
Confirming our hypothesis, we found an increase in coupling between the right amygdala and dorsomedial prefrontal cortex (PFC) for facial stimuli vs. shapes from T0 to T1 in the mechanism-based anti-aggression psychotherapy (MAAP)-BPD group compared to the non-specific supportive psychotherapy (NSSP)-BPD group
The results indicate a significant reduction in amygdala activation in response to facial stimuli from pre- to post-treatment timepoints in patients who took part in MAAP compared to those who took part in NSSP
Summary
Aggressive behavior, especially reactive aggression, is highly prevalent among female and male patients with borderline personality disorder (BPD) [1]. Mancke et al [2] identified biobehavioral mechanisms underlying reactive aggression in patients with BPD, including maladaptive anger regulation, deficits in mentalizing, approach rather than avoidance of threat and increased emotional contagion. One fundamental mechanism underlying aggressive behavior is threat sensitivity, processed in the neural threat circuit, with the amygdala playing a central role in processing threat cues [2,3]. Our group developed mechanism-based anti-aggression psychotherapy (MAAP), which aims at reducing aggressive behavior in patients with BPD by targeting the identified biobehavioral mechanisms, including threat sensitivity. In a randomized controlled trial (RCT), MAAP was compared to a non-specific supportive psychotherapy (NSSP) and was found to reduce overt aggressive behavior measured with the primary endpoint overt aggression scale modified (OAS-M, [4]) at 6 months follow-up [5]. In order to more accurately understand how psychotherapeutic treatments work and to evaluate and optimize treatments, it is important to understand the mechanisms of change, which have to be targeted to arrive at an effective treatment [6]
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