Neuroimaging in borderline personality disorder
Introduction
The past few years have seen a rapidly growing body of research in the field of neurobiological correlates of borderline personality disorder (BPD) (Lieb et al., 2004, Schmahl et al., 2002, Skodol et al., 2002). In addition to research on the genetic basis of the disorder (Jang et al., 1996, Torgersen et al., 2000), psychopharmacological treatment (Soloff, 2000), and neuroendocrinology (Rinne et al., 2002), progress in neuroimaging has been fruitful in the elucidation of the underlying neurobiology of this severe and chronic disorder.
Affective dysregulation has been suggested to represent the core of borderline symptomatology and to underlie most if not all of the characteristic features of the disorder, such as instable self image, disturbed interpersonal relationships, and self-injurious behavior. Animal studies as well as investigations in healthy human subjects suggest that limbic as well as prefrontal regions play a decisive role in emotion regulation (Davidson and Irwin, 1999). Thus, it can be hypothesized that frontolimbic dysfunction underlies affective dysregulation as well as other closely connected symptoms of BPD. Consequently, structural as well as functional neuroimaging investigations have focussed on alterations in these brain regions.
This review on neuroimaging in BPD is arranged according to the different imaging methods used. It will start with studies using volumetrics and spectroscopy of different brain regions, such as hippocampus, amygdala, and prefrontal regions. An overview of functional neuroimaging will begin with studies of brain metabolism under resting conditions using FDG-PET. Imaging of the serotonergic neurotransmission system using serotonergic agents will then be reviewed, followed by challenge studies that investigate reactivity of brain areas to stimuli such as emotional pictures, stressful memories, or sensory challenges with the aid of PET or functional MRI. Finally, conclusions from the literature reviewed will be drawn and an outlook on future studies will be given.
Section snippets
Volumetrics and spectroscopy
Neuroimaging research in the field of BPD began in the early 1980s with the use of computed tomography (CT). Similar to research on brain alterations in schizophrenic patients, whole brain volumes and ventricle sizes were investigated. In contrast to findings in schizophrenia, studies in BPD did not show ventricular enlargement (Schulz et al., 1983, Snyder et al., 1983), or changes in ventricle–brain ratio (Lucas et al., 1989) in patients with BPD. With the advent of Magnetic Resonance Imaging,
Brain metabolism under resting conditions assessed with FDG-PET
[18F]Deoxyglucose positron emission tomography (FDG-PET) can be used to assess baseline brain metabolism under resting conditions. The first study using FDG-PET in BPD was conducted by Goyer and coworkers (1994). Their investigation comprised 17 patients with DSM III-R personality disorders, six of which (four women and two men) were clinically diagnosed with BPD. However, the average score on the diagnostic interview for borderlines (DIB; Zanarini et al., 1989) in the BPD group was only 3.7,
Imaging of the serotonergic system
Impulsive aggression is part of the BPD phenotype and yet little is known about its neurobiology. Reduced serotonergic activity has been associated with impulsive aggression in metabolite and pharmacologic challenge studies, e.g. hormone responses to fenfluramine that increases serotonergic activity were shown to be abnormal in personality disordered patients with impulsive aggression (Coccaro et al., 1989). However, the neuroanatomical locus of this serotonergic dysfunction is still unclear.
Functional imaging studies with emotional, stressful, and sensory challenges
BPD was suggested to be part of a spectrum of stress-associated disorders together with PTSD, depression and dissociative disorders (Bremner, 2002) and reactivity to stress and stressful reminders appear to underlie affective dysregulation characteristic of patients with BPD. One method to test this reactivity is to expose subjects to emotional challenges or to stressful memories. Challenge studies are using either standardized materials such as emotional slides, or personalized material such
Summary, conclusions, and outlook
Neuroimaging research in BPD started about 20 years ago, and the last decade has brought an enormous increase in structural as well as functional imaging research. This research has been stimulated by neuroimaging investigations in Posttraumatic Stress Disorder and methodologies have been transferred from neuroimaging research in PTSD, e.g., volumetry of hippocampus and amygdala, or challenge studies with stressful autobiographical scripts. Since PTSD and BPD are both characterized by stressful
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