The rewarding nature of provocation-focused rumination in women with borderline personality disorder: a preliminary fMRI investigation

Jessica R Peters,C Nathan Dewall,David S Chester,Ruth A Baer,Erin C Walsh

doi:10.1186/s40479-018-0079-7

Abstract

BackgroundUnderstanding why individuals with borderline personality disorder (BPD) ruminate on prior provocations, despite its negative outcomes, is crucial to improving interventions. Provocation-focused rumination may be rewarding in the short term by amplifying anger and producing feelings of justification, validation, and increased energy, while reducing self-directed negative affect. If provocation-focused rumination is utilized regularly as a rewarding emotion regulation strategy, it could result in increased activation in reward-related neural regions. The present pilot study examined neural correlates of provocation-focused rumination, relative to other forms of thought, in BPD.MethodFunctional magnetic resonance imaging (fMRI) was utilized to examine this theory in a pilot study of women diagnosed with BPD (n = 13) and healthy controls (n = 16). All participants received highly critical feedback on a previously written essay in the scanner, followed by prompts to engage in provocation-focused, self-focused, and neutral thought.ResultsWhole-brain analyses showed that in response to the provocation, participants with BPD (compared to controls) demonstrated increased activation in the ventrolateral prefrontal cortex (PFC). BPD participants also showed greater activation in the dorsomedial PFC during provocation-focused rumination (relative to neutral-focus). Subsequent ROI analyses revealed that provocation-focused rumination (compared to neutral-focus) increased activation in the nucleus accumbens for the BPD group only.ConclusionsThese findings, while preliminary due to the small sample size and limitations of the protocol, provide initial data consistent with the proposed neurobiological mechanism promoting provocation-focused rumination in BPD. Directions for further research are discussed.

Highlights

Understanding why individuals with borderline personality disorder (BPD) ruminate on prior provocations, despite its negative outcomes, is crucial to improving interventions
Subsequent region of interest (ROI) analyses revealed that provocation-focused rumination increased activation in the nucleus accumbens for the BPD group only
While engaging in provocation-focused thought, relative to neutralfocus, all participants demonstrated greater activation in most of the regions previously associated with anger rumination and self-referential thought (DMPFC, dorsal anterior cingulate cortex (dACC)) [27], suggesting both groups engaged in the task; greater relative activation in regions of the dorsomedial prefrontal cortex (DMPFC) in provocation-focused thought in individuals with BPD, compared to controls, perhaps reflects greater intensity of engagement with the provocation stimuli for the BPD group

Summary

Introduction

Understanding why individuals with borderline personality disorder (BPD) ruminate on prior provocations, despite its negative outcomes, is crucial to improving interventions. Peters et al Borderline Personality Disorder and Emotion Dysregulation (2018) 5:1 crucial to understand why individuals with BPD tend to engage in rumination on provocations and anger despite its negative outcomes. The resulting amplified anger contributes to the aggression and interpersonal problems typical of BPD, potentially increasing risk of future social rejection and feelings of shame. Consistent with this theory, self-reported anger rumination and anger have been shown to mediate the relationship between shame-proneness and BPD features in a student sample [13], and individuals diagnosed with BPD have been shown to react strongly to rejection cues with rage [17]

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