Abstract
ObjectivesRepetitive transcranial magnetic stimulation (rTMS) is an innovative method in the treatment of borderline personality disorder (BPD). We hypothesized that prefrontal rTMS in patients with BPD leads to improved BPD symptoms and that these effects are associated with brain connectivity changes.MethodsFourteen patients with BPD received 15 sessions of individually navigated prefrontal rTMS over the right dorsolateral prefrontal cortex. Clinical effects were measured by the Borderline Symptom List 23, UPPS-P, the Difficulties in Emotion Regulation Scale (DERS), the Zung Self-Rating Anxiety Scale (SAS), and the Montgomery and Åsberg Depression Rating Scale (MADRS). Effects of rTMS on brain connectivity were observed with a seed correlation analysis on resting-state fMRI and with a beta series correlation analysis on Go/No Go tasks during fMRI. Assessments were made before and immediately after the treatment.ResultsThe assessments after rTMS showed significant reductions in two subscales of UPPS-P, and in DERS, SAS, and MADRS. The brain connectivity analysis revealed significant decreases in amygdala and insula connectivity with nodes of the posterior default mode network (pDMN; precuneus, posterior cingulate cortex, parietal lobules). Connectivity changes were observed both in the resting state and during inhibition. The decrease of amygdala-pDMN connectivity was positively correlated with reduced depression and lack of premeditation after rTMS.ConclusionsDespite the study limitations (open single-arm study in a small sample), our findings suggest a possible neural mechanism of rTMS effect in BPD, reduced amygdala connectivity with the pDMN network, which was positively associated with symptom reduction.
Highlights
Borderline personality disorder (BPD) is a serious mental disorder characterized by instability of affect, self-image, and relationships, and by marked impulsivity including self-harm and recurrent suicidal behavior [1]
We focused on exploring changes in brain connectivity in three regions of interest: the dorsolateral prefrontal cortex (DLPFC), a brain area crucial for emotion and impulse regulation [25, 26] and a stimulation target in this study; the amygdala, a brain area associated with emotion experiencing intensity that is hyperactive in patients with BPD [9]; and the insula, a crucial node in the inhibition network [24] and a brain area associated with experiencing negative emotions [27].To maximize the possibility of rTMS enhancing self-control and decreasing impulsivity, we chose individual neuronavigation of the rTMS target based on the functional magnetic resonance imaging (fMRI) results of a Go/NoGo task
Emotion regulation was measured by the Difficulties in Emotion Regulation Scale [DERS; [33]], and anxiety was measured by the Zung Self-Rating Anxiety Scale [significant reduction of anxiety symptoms (SAS); [34]]
Summary
Borderline personality disorder (BPD) is a serious mental disorder characterized by instability of affect, self-image, and relationships, and by marked impulsivity including self-harm and recurrent suicidal behavior [1]. Patients with BPD have been reported to show increased involvement of the posterior default mode network [6, 7] and increased connectivity of the anterior cingulate cortex with the amygdala and insula [8]. Patients with BPD show increased and prolonged reactivity of the amygdala, altered prefrontal cortex responses, including the dorsolateral prefrontal cortex (DLPFC), and reduced connectivity between limbic and prefrontal regions as compared to healthy controls in functional magnetic resonance imaging (fMRI) studies [9,10,11,12]. Impaired prefrontal-limbic connections are typically described as a mechanism of impaired top-down emotional control in BPD, leading to increased impulsivity and impaired emotion regulation
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