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Using Dialectical Behavioral Therapy (DBT) to help mitigate symptoms of Borderline Personality Disorder (BPD)

  • Writer: Adriana Bello
    Adriana Bello
  • 6 days ago
  • 9 min read

Updated: 2 days ago


Introduction 

When a group of patients did not fit into the psychotic or psychoneurotic category, Dr. Adolph Stern—American psychiatrist and psychoanalyst—labeled patients to be “borderline”. The introduction of the term “borderline personality” was proposed by Stern in the U.S. in 1938 and the term was then continued to be used formally (National Collaborating Centre for Mental Health, 2009).


Dr. Adolph Stern (1878-1958)
Dr. Adolph Stern (1878-1958)

The National Alliance on Mental Illness (2023) stated that an estimated 1.4% of the United States adult population lives with BPD—and about 75% of individuals diagnosed with Borderline Personality Disorder are women. The diagnostic criteria for BPD includes symptoms such as intense mood swings, impulsivity, efforts to avoid real or perceived abandonment, a pattern of unstable and/or intense relationships with people, and self-harming behavior such as self-mutilation.


At the moment, researchers are not sure what the neurobiological cause of BPD is. Studies have suggested that there may be a wide range of genetic, social, and environmental factors that can affect an individual, and possibly increase their probability of developing BPD. There is also no medication or treatment that “cures” one from having BPD, but well-known medications such as mood stabilizers and antidepressants can help individuals living with BPD, mitigate their symptoms of the disorder. Another method psychiatrists recommend for patients is the use of

Dr. Marsha Linehan
Dr. Marsha Linehan

psychotherapies such as Dialectical Behavioral Therapy (DBT). DBT is a type of talk therapy that is recommended for those who experience intense emotions. DBT is a common therapy recommended for those who live with Borderline Personality Disorder as it helps patients accept their behaviors and life for what it is, while also helping individuals find ways in which they can make their lives fulfilling and rid themselves of unhelpful behaviors. DBT was first developed in the 1970’s by American psychologist Dr. Marsha Linehan.



DBT is also used for a wide range of symptoms and disorders including PTSD, substance use disorder, and those suffering from an eating disorder (Cleveland Clinic, 2022). Past neuroimaging research has suggested that fronto-limbic dysfunction is what underlies the affective instability found in patients with BPD. Research has also found that affective hyperarousal is a target symptom for DBT treatment in patients with BPD. Such hyperarousal has been associated with increased activity in the amygdala and the insula—areas that are involved in emotion processing (Winter et al., 2016). The reduced ability to downregulate areas such as the amygdala and insula has been evident in past research—but what other areas of the brain are also active in patients with BPD?


DBT has worked to help mitigate various symptoms of BPD in patients, but how does this work exactly?


Effective treatments such as DBT for patients living with BPD can help improve the lives of individuals and help reduce impulsive behaviors in patients. As BPD can also sometimes be associated with thoughts of suicide, such treatments can help reduce the risk of suicide in patients living with this disorder which can be both mentally and emotionally draining. We'll examine what the brain basis of the ability for Dialectical Behavioral Therapy to help mitigate symptoms of Borderline Personality Disorder can potentially look like by reviewing three different studies conducted by researchers who asked what the neural correlates and effects of DBT are on patients living with BPD.


All research papers are hyperlinked and can be found in the "References" section.


Knut Schnell and Sabine Herpertz (2006) published a research study testing what the effects of DBT are on the neural correlates of affective hyperarousal in patients with BPD. Patients with BPD often suffer from affect dysregulation—a leading symptom of psychopathology. Affect dysregulation or emotional dysregulation is known as the inability to properly express or manage intense feelings and emotions. Affective hyperarousal is known as a heightened state of emotional reactivity. In this study, researchers aimed to examine if after receiving DBT treatment, patients with BPD—with the hopes of having increased regulation of affective arousal—would translate these changes in their neural systems that are involved in affect or emotional regulation. The researchers also hypothesized that prefrontal cortical and subcortical areas—in particular the amygdala—would demonstrate major changes in patients with BPD under DBT treatment. Six patients who were medication free and female, participated in this study.


Each patient participated in a 12-week DBT in-patient treatment program. The fMRI scans helped researchers acquire BOLD (blood oxygenation level dependent) signal contrast images. This fMRI study had an experimental design that featured a behavioral intervention, whereby patients were presented with 100 pseudorandomized pictures for each of the five fMRI sessions. The subjects were then asked to rate each picture immediately after each scanning procedure. The analysis of any functional changes in the brain in patients who were undergoing DBT treatment was observed by the blood-oxygenation level dependent (BOLD) responses to high arousal negative stimuli before and after DBT treatment. 


Figure 3 panel T2 in Schnell and Herpertz's paper showed that prior to DBT treatment, patients with BPD showed a greater activation in dorsolateral and dorsomedial frontal areas of both hemispheres of the brain. Patients also displayed greater activation in the left caudal cingulate gyrus and in the left superior temporal gyrus. In panel t5, patients and controls after treatment revealed fewer areas of increased activation in the brain. Patients with a BOLD-response being measured demonstrated a significant increase in activation of the posterior cingulate gyrus—a structure involved with emotion.


Researchers concluded that patients with BPD after they have received DBT treatment also showed a significant reduction in activity in their caudal anterior cingulate cortex (ACC). The caudal ACC is known to monitor emotional salience, and decreased reactivity in this part of the brain may indicate that patients in the study needed less additional cognitive effort to regulate their emotional responses.


In another study conducted by Dorina Winter et al. (2016) researchers asked what the neural correlates of distraction are in patients with BPD after undergoing DBT treatment. Distraction in this study was investigated as it is a main emotion regulation strategy that is taught as a self-administered cognitive intervention to reduce high levels of strong emotions. Researchers hypothesized that patients with BPD who underwent DBT treatment would display an increased use of a regulation network located in the frontoparietal areas of the brain. The patients were all measured using fMRI imaging and were also assessed using the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), the Difficulties in Emotion Regulation Scale (DERS), and a self-report measure known as the Borderline Symptom List (BSL).


This experiment instructed patients to view and memorize five consonants which were presented for 2000 ms. After each picture was presented, patients had to indicate where or not a probe letter that was presented was found in the letter string before a picture. Pictures that were presented were either low in valence, high in arousal or had an intermediate valence, and were low in arousal.


In panel B of figure 1 of the paper patients were assessed through a standardized clinical interview using the ZAN-BPD. Patients with BPD who underwent DBT treatment showed a decrease in all psychometric measures between t1 and t2 (before and after DBT). Patients with BPD who were receiving DBT treatment self-reported a decrease in DERS scores after DBT treatment as was shown in panel C of figure 1. Therefore, patients felt that their difficulties in emotion regulation was lessened after receiving therapy. In comparison to BPD patients who did not receive DBT treatment, these patients self-reported to feel no improvement in their DERS scores. These changes were also present in the brains of patients with BPD who underwent DBT as DBT responders showed decreased pregenual anterior cingulate cortex (pgACC) activity while viewing negative compared with neutral stimuli. Researchers state that the pgACC is “thought to reflect the automatic, attentional regulation of negative affect” (Winter et al., 2016). Therefore, the decrease in activity of the pgACC may reflect a lesser impact of viewing a negative stimuli in comparison to a neutral stimuli after receiving DBT.


Researchers however, did not find that BPD symptom improvement was associated with reduced limbic hyper-reactivity during distraction tasks. Overall, the pgACC was the most relevant brain region throughout the entirety of the experiment.


In the last research article by Ruth Schmitt et al. (2016) researchers used fMRI to investigate what the neural correlates of explicit emotion regulation are before and after a patient receives DBT treatment. As previously described in the introduction, emotion dysregulation continues to be one of the key characteristics of BPD. Past research has shown that “negative emotionality” in patients with BPD exhibits greater insula and posterior cingulate cortex activation, as well as lower dorsolateral prefrontal cortex (DLPFC) activity. One factor of emotional dysregulation that researchers decided to take a further look at was reappraisal, as one of the factors contributing to emotion dysregulation in BPD is the difficulty in using reappraisal as an emotion regulating strategy.


In this study, researchers hypothesized that patients with BPD who responded to DBT treatment would show a downregulation of brain activity in regions associated with limbic hyperarousal—which includes both the amygdala and the insula. Researchers also hypothesized that patients would show elevated limbic prefrontal network connectivity during reappraisal of negative pictures. Researchers used fMRI imaging and behavioral data to acquire information throughout the experiment when presenting visual stimuli through presentation software via MRI-compatible goggles. 


Figure 1 panel A shows patients with BPD who underwent DBT treatment who exhibited reduced anterior insula activity after, compared with before, DBT compared to healthy control patients. Panel B also showed changes in patients' dorsal anterior cingulate cortex as reappraisal activity decreased, compared to healthy controls. The results above highlight the decreased anterior insula and dorsal anterior cingulate cortex (ACC) activity during reappraisal of negative pictures after DBT. Researchers were able to show the ability in patients to downregulate limbic hyperactivation when using reappraisal as an emotion regulation strategy after successful DBT treatment. The study showed that reduced anterior insula and dorsal ACC activation was present during reappraisal tasks after successful DBT treatment. Both areas of the brain are involved in emotion processing and are major salience network hubs. Researchers were able to find that reduced activity in areas such as the anterior insula was also linked to affective dysregulation symptom reduction, suggesting that this brain area in particular may be a neural substrate of improved emotion regulation.


Reduced amygdala activity during reappraisal could not be detected in the DBT group as a whole, therefore, the most significant findings of this study are in accordance to reduced brain activity in brain regions that are associated with salience processing and attentional control—what an individual decides to pay attention to. 


Conclusion

The findings across all three research studies add to the refinement of our

understanding of Borderline Personality Disorder from a biological perspective. The three research articles dissected throughout this paper have demonstrated the impact of Dialectical Behavioral Therapy on patients living with BPD. By using fMRI imaging, researchers were able to determine the most significant brain regions that were activated during distraction, appraisal, and emotionally arousing tasks to investigate affective hyperarousal, and how emotion overall is regulated differently before versus after a patient with BPD received DBT treatment.


Therefore, the brain basis of the ability for Dialectical Behavioral Therapy to help mitigate symptoms of Borderline Personality Disorder is by decreasing the activity of the cACC, pgACC, and dACC—brain regions that are responsible for attentional control, emotion regulation, and salience processing. By using emotion regulation strategies such as reappraisal and distraction, individuals with BPD with the help of therapies such as DBT are able to induce stronger connections between their PFC and limbic system. These connections allow a patient to reframe their thinking and allow high arousal stimuli to affect one less. The correlation of the following brain structures and the improvement in regulating emotion and cognitive approaches to stimuli following DBT indicate that DBT plays a part in altering the brain activity in regions associated with both cognitive control and emotion regulation. DBT has also shown to lead to a down-regulation in structures such as the amygdala and insula found in the limbic system emphasizing DBTs ability to help patients respond to stressful stimuli and situations with less impulsivity and less emotional volatility.


The studies that we reviewed today allow us to ultimately conclude that DBT can help alleviate symptoms of BPD and contribute to positive long-term neurological changes ☺︎



References:

All figures have been mentioned and can be found in the referenced research papers. GreyMatters does not accept commission or make profit off of any post. All credits go to every author listed above. If you believe we have reproduced/cited/quoted your content in any way that does not align with its meaning and value, please contact us as soon as possible. Thank you.

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