title: 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; VISN 3 Mental Illness Research, Education, and Clinical Center (MIRECC), James J. Peters VA Medical Center, Bronx, NY, USA; Oupatient Psychiatry, James J. Peters VA Medical Center, Bronx, NY, USA. Electronic address: marianne.goodman@va.gov.
authors.forename: Marianne
authors.initials: M
authors.lastname: Goodman
authors.affiliation: Department of Radiology, Icahn School of Medicine at Mount Sinai, USA.
authors.forename: David
authors.initials: D
authors.lastname: Carpenter
authors.affiliation: Department of Radiology, Icahn School of Medicine at Mount Sinai, USA.
authors.forename: Cheuk Y
authors.initials: CY
authors.lastname: Tang
authors.affiliation: Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Kim E
authors.initials: KE
authors.lastname: Goldstein
authors.affiliation: VISN 3 Mental Illness Research, Education, and Clinical Center (MIRECC), James J. Peters VA Medical Center, Bronx, NY, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Avedon
authors.affiliation: VISN 3 Mental Illness Research, Education, and Clinical Center (MIRECC), James J. Peters VA Medical Center, Bronx, NY, USA.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Fernandez
authors.affiliation: VISN 3 Mental Illness Research, Education, and Clinical Center (MIRECC), James J. Peters VA Medical Center, Bronx, NY, USA.
authors.forename: Kathryn A
authors.initials: KA
authors.lastname: Mascitelli
authors.affiliation: VISN 3 Mental Illness Research, Education, and Clinical Center (MIRECC), James J. Peters VA Medical Center, Bronx, NY, USA.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Blair
authors.affiliation: Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; VISN 3 Mental Illness Research, Education, and Clinical Center (MIRECC), James J. Peters VA Medical Center, Bronx, NY, USA.
authors.forename: Antonia S
authors.initials: AS
authors.lastname: New
authors.affiliation: Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Oupatient Psychiatry, James J. Peters VA Medical Center, Bronx, NY, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Triebwasser
authors.affiliation: Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; VISN 3 Mental Illness Research, Education, and Clinical Center (MIRECC), James J. Peters VA Medical Center, Bronx, NY, USA; Oupatient Psychiatry, James J. Peters VA Medical Center, Bronx, NY, USA.
authors.forename: Larry J
authors.initials: LJ
authors.lastname: Siever
authors.affiliation: Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; VISN 3 Mental Illness Research, Education, and Clinical Center (MIRECC), James J. Peters VA Medical Center, Bronx, NY, USA.
authors.forename: Erin A
authors.initials: EA
authors.lastname: Hazlett
mesh_terms: D000293:Adolescent; D000328:Adult; D000679:Amygdala / Q000503:physiopathology*; D001521:Behavior Therapy / Q000379:methods*; D001883:Borderline Personality Disorder / Q000503:physiopathology* / Q000523:psychology / Q000628:therapy*; D016022:Case-Control Studies; D004644:Emotions; D005149:Facial Expression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D010775:Photic Stimulation; D013997:Time Factors; D016896:Treatment Outcome; D014796:Visual Perception; D055815:Young Adult
keywords: Amygdala; Borderline personality disorder; Emotion regulation; Habituation; fMRI