Anna Buchheim

Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial

BACKGROUND Transference-focused psychotherapy is a manualised treatment for borderline personality disorder. AIMS To compare transference-focused psychotherapy with treatment by experienced community psychotherapists. METHOD In a randomised controlled trial (NCT00714311) 104 female out-patients were treated for 1 year with either transference-focused psychotherapy or by an experienced community psychotherapist. RESULTS Significantly fewer participants dropped out of the transference-focused psychotherapy group (38.5% v. 67.3%) and also significantly fewer attempted suicide (d = 0.8, P = 0.009). Transference-focused psychotherapy was significantly superior in the domains of borderline symptomatology (d = 1.6, P = 0.001), psychosocial functioning (d = 1.0, P = 0.002), personality organisation (d = 1.0, P = 0.001) and psychiatric in-patient admissions (d = 0.5, P = 0.001). Both groups improved significantly in the domains of depression and anxiety and the transference-focused psychotherapy group in general psychopathology, all without significant group differences (d = 0.3-0.5). Self-harming behaviour did not change in either group. CONCLUSIONS Transference-focused psychotherapy is more efficacious than treatment by experienced community psychotherapists in the domains of borderline symptomatology, psychosocial functioning, and personality organisation. Moreover, there is preliminary evidence for a superiority in the reduction of suicidality and need for psychiatric in-patient treatment.

Changes in Prefrontal-Limbic Function in Major Depression after 15 Months of Long-Term Psychotherapy

Neuroimaging studies of depression have demonstrated treatment-specific changes involving the limbic system and regulatory regions in the prefrontal cortex. While these studies have examined the effect of short-term, interpersonal or cognitive-behavioural psychotherapy, the effect of long-term, psychodynamic intervention has never been assessed. Here, we investigated recurrently depressed (DSM-IV) unmedicated outpatients (N = 16) and control participants matched for sex, age, and education (N = 17) before and after 15 months of psychodynamic psychotherapy. Participants were scanned at two time points, during which presentations of attachment-related scenes with neutral descriptions alternated with descriptions containing personal core sentences previously extracted from an attachment interview. Outcome measure was the interaction of the signal difference between personal and neutral presentations with group and time, and its association with symptom improvement during therapy. Signal associated with processing personalized attachment material varied in patients from baseline to endpoint, but not in healthy controls. Patients showed a higher activation in the left anterior hippocampus/amygdala, subgenual cingulate, and medial prefrontal cortex before treatment and a reduction in these areas after 15 months. This reduction was associated with improvement in depressiveness specifically, and in the medial prefrontal cortex with symptom improvement more generally. This is the first study documenting neurobiological changes in circuits implicated in emotional reactivity and control after long-term psychodynamic psychotherapy.

Measuring Attachment Representation in an fMRI Environment: A Pilot Study

This exploratory study is the first to examine the neural correlates of attachment status in adults. The study examined the feasibility of assessing attachment narratives in the functional magnetic resonance imaging (fMRI) environment by challenging subjects to tell attachment stories to specific attachment pictures from the Adult Attachment Projective (AAP) while being scanned. We investigated theoretically derived hypotheses regarding predicted differences in the brain activation patterns of individuals whose attachment status was organized (resolved) versus disorganized (unresolved) with respect to attachment trauma (e.g., as associated with loss through death, abuse, threat of abandonment). Adult attachment was assessed using the AAP, a new representational attachment measure that we thought might be suitable for use in the fMRI environment. This measure was used to obtain a preliminary picture of the neural processes associated with the activation of attachment in 11 healthy female adults. Results are reported from a second-level analysis (p < 0.001 uncorrected) and confirm that the AAP is a feasible measure for use in a neuroimaging environment. Cerebral activation during continuous speech yielded results consistent with the literature. Brain activation was demonstrated in expected visual and semantic brain regions. Furthermore, we found that the rate of articulation was positively correlated with activation in the right superior temporal gyrus. The results of theoretically derived attachment hypotheses showed no differences at the chosen level of significance when comparing the ‘all attachment pictures’ effect between both groups (resolved vs. unresolved). More interestingly, we found a significant interaction effect between the sequence of pictures and attachment category. Only the unresolved participants showed increasing activation of medial temporal regions, including the amygdala and the hippocampus, in the course of the AAP task. This pattern was demonstrated especially at the end of the AAP task where the pictures are drawn to portray traumatic situations. We interpret these results as confirming our hypothesis, linking unresolved attachment to emotional dysregulation of the attachment system. These results are discussed in relation to assessing attachment in an fMRI environment and future research in this area.

Oxytocin modulates neural reactivity to children's faces as a function of social salience.

Oxytocin (OT) enhances social behaviors such as attachment and parental caretaking. Neural correlates of maternal attachment are found in reward-related brain regions, for example, in the globus pallidus (GP). The present work investigates the effects of OT on the neural correlates of parental attachment. Fathers viewed pictures of their own child (oC), a familiar child (fC), and an unfamiliar child (uC) after intranasal application of OT vs placebo. OT reduced activation and functional connectivity of the left GP with reward- and attachment-related regions responsive to pictures of the oC and the uC. The present results emphasize the key role of OT in human parental attachment and suggest that OT reduces neural reactivity to social cues as a function of social salience. Our results together with previous findings speak to a selective reduction of neural reactivity to social stimuli, irrespective of their valence. We argue that one major pathway by which OT exerts its positive effects on affiliative and social behaviors is the attenuation of automatic neural responses, which in turn leads to increased approach behaviors and decreased social avoidance.

THE INFLUENCE OF PREMATURITY, MATERNAL ANXIETY, AND INFANTS' NEUROBIOLOGICAL RISK ON MOTHER-INFANT INTERACTIONS

In this study, we investigated how the birth of a very low birth weight preterm (VLBW) infant influences the mother-infant interaction at 3 months. We also focused on the impact of the infants neurobiological risk and maternal anxiety, and their interaction. The comparison of the VLBW preterm sample (n = 79) with an external full-term sample (n = 35) showed mother-infant interactions of the families with the preterm infant to be more vocally responsive during the interaction, but less facially responsive during the interaction. Additionally, higher levels of maternal anxiety were associated with preterm infants being less facially responsive in interaction with their mother. While neurobiological risk of the infant played a part in this association, with higher risk infants also being less facially responsive, the relationship with maternal anxiety and the mother-child interaction was stronger. How these findings may influence therapeutic interventions is discussed.

The Relationship Among Attachment Representation, Emotion-Abstraction Patterns, and Narrative Style: A Computer-Based Text Analysis of the Adult Attachment Interview

The main aim of this research was to test the discriminant capacity of computer-based, linguistic text measures which are economically compilable (Emotion-Abstraction Patterns, Mergenthaler, 1996; Computerized Referential Activity, Mergenthaler & Bucci, 1999) in differentiating between complex attachment representations in the Adult Attachment Interview (Main & Goldwyn, 1994). The study of N = 40 healthy controls produced the consistent result that, of the two insecure attachment categories, the group ‘dismissing’ (n = 10) showed the lowest means on all text measures, whereas the group ‘preoccupied’ (n = 10) showed the highest means. The mean of the attachment group ‘secure’ (n = 20) lay between these groups. This ranking is consistent with the results of studies which had another research focus, showing deactivation or hyperactivation of attachment-relevant information in both insecure attachment groups, as well as flexibility in the ‘secure’ group. We also discuss whether the coincidence of language markers for emotion and abstraction, as well as Computerized Referential Activity, is adequate to operationalize the construct of coherence in narrative style.

Individualized and Clinically Derived Stimuli Activate Limbic Structures in Depression: An fMRI Study

Objectives In the search for neurobiological correlates of depression, a major finding is hyperactivity in limbic-paralimbic regions. However, results so far have been inconsistent, and the stimuli used are often unspecific to depression. This study explored hemodynamic responses of the brain in patients with depression while processing individualized and clinically derived stimuli. Methods Eighteen unmedicated patients with recurrent major depressive disorder and 17 never-depressed control subjects took part in standardized clinical interviews from which individualized formulations of core interpersonal dysfunction were derived. In the patient group such formulations reflected core themes relating to the onset and maintenance of depression. In controls, formulations reflected a major source of distress. This material was thereafter presented to subjects during functional magnetic resonance imaging (fMRI) assessment. Results Increased hemodynamic responses in the anterior cingulate cortex, medial frontal gyrus, fusiform gyrus and occipital lobe were observed in both patients and controls when viewing individualized stimuli. Relative to control subjects, patients with depression showed increased hemodynamic responses in limbic-paralimbic and subcortical regions (e.g. amygdala and basal ganglia) but no signal decrease in prefrontal regions. Conclusions This study provides the first evidence that individualized stimuli derived from standardized clinical interviewing can lead to hemodynamic responses in regions associated with self-referential and emotional processing in both groups and limbic-paralimbic and subcortical structures in individuals with depression. Although the regions with increased responses in patients have been previously reported, this study enhances the ecological value of fMRI findings by applying stimuli that are of personal relevance to each individuals depression.

Electrophysiological correlates of error processing in borderline personality disorder.

The electrophysiological correlates of error processing were investigated in patients with borderline personality disorder (BPD) using event-related potentials (ERP). Twelve patients with BPD and 12 healthy controls were additionally rated with the Barratt impulsiveness scale (BIS-10). Participants performed a Go/Nogo task while a 64 channel EEG was recorded. Three ERP components were of special interest: error-related negativity (ERN)/error negativity (Ne), early error positivity (early Pe) reflecting automatic error processing, and the late Pe component which is thought to mirror the awareness of erroneous responses. We found smaller amplitudes of the ERN/Ne in patients with BPD compared to controls. Moreover, significant correlations with the BIS-10 non-planning sub-score could be demonstrated for both the entire group and the patient group. No between-group differences were observed for the early and late Pe components. ERP measures appear to be a suitable tool to study clinical time courses in BPD.

Response inhibition in borderline personality disorder : event-related potentials in a Go/Nogo task

Summary.Borderline personality disorder (BPD) has been related to a dysfunction of anterior cingulate cortex, amygdala, and prefrontal cortex and has been associated clinically with impulsivity, affective instability, and significant interpersonal distress. We examined 17 patients with BPD and 17 age-, sex-, and education matched control participants with no history of Axis I or II psychopathology using event-related potentials (ERPs). Participants performed a hybrid flanker-Go/Nogo task while multichannel EEG was recorded. Our study focused on two ERP components: the Nogo-N2 and the Nogo-P3, which have been discussed in the context of response inhibition and response conflict. ERPs were computed on correct Go trials (button press) and correct Nogo trials (no button press), separately. Groups did not differ with regard to the Nogo-N2. However, BPD patients showed reduced Nogo-P3 amplitudes. For the entire group (n = 34) we found a negative correlation with the Barratt Impulsiveness Scale (BIS-10) and Becks’s depression inventory (BDI).The present study is the first to examine Nogo-N2 and Nogo-P3 in BPD and provides further evidence for impaired response inhibition in BPD patients.

The Role of Mentalization in the Psychoanalytic Treatment of Chronic Depression

Mentalization has been proposed as a key concept in understanding therapeutic change in patients with Borderline Personality Disorder (BPD). However, little is known about mentalization in chronic depression. This study investigated the role of mentalization in the long-term psychoanalytic treatment of chronic depression. Mentalization measured with the Reflective Functioning Scale (RFS) was examined in patients with chronic depression (n = 20) in long-term psychoanalytic treatment and compared to healthy controls (n = 20). Results show that global RF scores did not differ significantly between patients and controls. However, depressed patients tended to have lower RF scores concerning issues of loss. Furthermore, RF was unrelated to symptoms and distress as assessed by the Beck Depression Inventory (BDI) and the SCL-90. RF did not predict therapeutic outcome as measured with the BDI but predicted changes in general distress after 8 months of psychoanalytic treatment as measured by the SCL-90. Moreover, correlations between RF and the Helping Alliance Questionnaire indicated that patients with higher RF were able to establish a therapeutic alliance more easily compared to patients with low RF.