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.

Keywords: Amygdala; Borderline personality disorder; Emotion regulation; Habituation; fMRI.

Conflict of interest statement

Conflict of interest

None of the authors have any biomedical financial interests or potential conflicts of interest to declare.

Published by Elsevier Ltd.

Figures

Fig. 1

A schematic of the event-related picture processing fMRI task paradigm is shown. Participants viewed an intermixed series of unpleasant, neutral, and pleasant pictures for 6-s each. Following each picture, they were prompted with a screen to make a 3-choice button press to rate how the picture made them feel (unpleasant, neutral, or pleasant). Some trials had no picture presented during the 6-s period (see Methods section for additional details).

Fig. 2

DERS total scores for the HC and BPD groups at baseline (0), 6 months, and 12 months. DERS scores showed a decline with DBT treatment in the BPD group, but were stable over time for the HC group, Group × Time interaction, F[2,36] = 3.71, p < 0.04, H–F, epsilon = 1.00.

Fig. 3

Compared with the healthy control (HC) group (which was yoked and did not receive treatment), the BPD group showed a pattern of higher amygdala activity at baseline (pre-treatment) that decreased following a standard 12-month DBT intervention. The HC group was scanned to provide a benchmark for normal amygdala activity at baseline and a 12-month interval. *p = 0.08, Fisher’s LSD post-hoc, trend-level.

Fig. 4

Compared with healthy controls, the individuals with BPD showed a pattern of greater decrease from pre- to post-treatment in amygdala activity for all three pictures types, but particularly in the left hemisphere and during the repeated emotional (unpleasant, pleasant) picture conditions (see red boxes in figure), Group × Time × Picture type × Picture repetition × Hemisphere interaction, F[2,19] = 3.71 p < 0.05. None of the post-hoc tests were significant. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 5

Scatterplots and Pearson correlation coefficients for the BPD group show the relationship between change (pre-treatment minus post-treatment, i.e. 0–12 months) in amygdala activation to repeated unpleasant pictures and emotional regulation (measured by change in the DERS total score (Top) and the DERS strategy subscale (Bottom). Among the patient group, greater reduction in amygdala activity to repeated-unpleasant pictures (i.e. better habituation) following DBT was associated with greater clinical improvement in emotional regulation and use of emotion regulation strategies.