Wolfgang Lange

Posttraumatic stress disorder and fMRI activation patterns of traumatic memory in patients with borderline personality disorder.

BACKGROUND Early traumatization and additional posttraumatic stress disorder are frequent in patients with borderline personality disorder (BPD). The purpose of this study was to investigate neural correlates of traumatic memory in BPD with and without posttraumatic stress disorder (PTSD) using functional magnetic resonance imaging (fMRI). METHODS We studied 12 traumatized female patients BPD, 6 of them with and 6 without PTSD. According to an autobiographical interview key words (cues) were defined for traumatic and for negative but nontraumatic episodes. In a block-designed fMRI task patients recalled these episodes. Contrasts between trauma condition and nontrauma condition were analyzed. RESULTS Analyses for all subjects revealed activation of orbitofrontal cortex areas in both hemispheres, anterior temporal lobes, and occipital areas. In the subgroup without PTSD, activation of orbitofrontal cortex on both sides and Brocas area predominated. In the subgroup with additional PTSD, we observed right more than left activation of anterior temporal lobes, mesiotemporal areas, amygdala, posterior cingulate gyrus, occipital areas, and cerebellum. CONCLUSIONS Dependent on absence or presence of additional PTSD different neural networks seem to be involved in the traumatic memory of patients with BPD.

Functional MRI correlates of the recall of unresolved life events in borderline personality disorder

BACKGROUND Patients with borderline personality disorder (BPD) frequently report unresolved life events but it is still poorly understood, how these experiences are represented in the brain. Using functional magnetic resonance imaging (fMRI), the present study aimed at investigating the neural correlates of the recall of unresolved life events in patients with BPD and healthy controls. METHOD Twenty female BPD patients and 21 healthy control subjects underwent fMRI. During measurement subjects recalled unresolved and resolved negative life events. Individual cue words were used to stimulate autobiographical memory. After scanning, subjects rated their emotional states during the recall of both types of memories. RESULTS When contrasting unresolved and resolved life events, patients showed significant bilateral activation of frontotemporal areas including the insula, amygdala, and the anterior cingulate cortex, the left posterior cingulate cortex, right occipital cortex, the bilateral cerebellum and the midbrain. In healthy subjects, no differential brain activation was related to these conditions. The 2 x 2 factorial analysis (DeltaBPD - Deltacontrols) revealed similar results with bilateral activation of the frontal cortex including parts of the insula and of the orbitofrontal cortex, temporal activation including the amygdala, activation of the right occipital cortex, and parts of the cerebellum. Patients but not controls reported higher levels of anxiety and helplessness during the unresolved versus resolved memory condition. CONCLUSIONS The activation of both, the amygdala and prefrontal areas, might reflect an increased effortful but insufficient attempt to control intensive emotions during the recall of unresolved life events in patients with BPD.

Deficits in visual functions and neuropsychological inconsistency in Borderline Personality Disorder

For Borderline Personality Disorder (BPD) cognitive and perceptual impairments were reported in some but not all studies. The aim of the present study was to analyze the neuropsychological performance of BPD patients in different domains. Predominant impairments of visual functions and an increased intra-individual variation of test performances within neuropsychological domains were expected. We investigated 22 patients with BPD and a matched sample of 22 healthy control subjects. A comprehensive clinical and neuropsychological test battery was administered. Effect sizes indicate primarily deficits of visual functions such as visual memory (Wechsler Memory Scale-Revised, WMS-R: Visual pair associates and visual reproduction, Complex Figure Test: Recall) and visuo-spatial abilities (Leistungspruefsystem, LPS 9 and 10: Spatial imagination and embedded figures), but also of executive functions (Tower of Hanoi, Trail Making Test-B, semantic and figural fluency, LPS 4: Reasoning). In addition, the intra-individual ranges of neuropsychological test results in BPD patients were increased compared to those of healthy subjects. This finding might be due to a high degree of temporary stress that interferes with effective cognitive processing. Further research is needed to confirm the present results and to control for stress during the test procedure.

Dexamethasone suppression test in borderline personality disorder—effects of posttraumatic stress disorder

BACKGROUND Divergent findings of hypothalamic-pituitary-adrenal (HPA) axis functioning in borderline personality disorder (BPD) may be caused by a different degree of comorbid posttraumatic stress disorder (PTSD), in which alterations of the HPA axis are well known. Here we investigate alterations of the HPA axis in BPD patients with and without comorbid PTSD compared to healthy controls. Considering previous findings current major depression (MDD) was taken into account as a confounding variable. METHODS Apart from clinical assessment the 0.5 mg dexamethasone suppression test (DST) was performed in 21 female borderline patients and 23 healthy controls. RESULTS Twelve BPD patients suffered from comorbid PTSD. Relative suppression (%) did not differ between healthy controls and the total BPD group, but BPD patients with comorbid PTSD showed increased suppression compared to those without. Comorbid MDD was not associated with suppression. CONCLUSIONS Our results do not indicate a dysfunction of the HPA axis in BPD. However, comorbid PTSD seems to be associated with a relative hypersuppression in the 0.5 mg DST.

Ist die Borderline-Persönlichkeitsstörung eine komplexe posttraumatische Störung? Zum Stand der Forschung

ZusammenfassungAusgehend von der hohen Prävalenz traumatisierender Erfahrungen in der Vorgeschichte von PatientInnen mit Borderline-Persönlichkeitsstörung (BPD) geht diese Übersicht der Frage nach, inwieweit die BPD als eine Form traumaassoziierter Störungen aufgefasst werden kann. Außer klinisch-phänomenologischen Überschneidungen mit den Konzepten der komplexen posttraumatischen Belastungsstörung (PTSD) und der “disorders of extreme stress not otherwise specified (DESNOS)” konvergieren auch Befunde zum Langzeitverlauf und Befunde zu möglichen Vulnerabilitätsfaktoren. Unter Berücksichtigung der allgemeinen Stressforschung und ähnlicher neuropsychologischer Defizite bei BPD und PTSD sprechen darüber hinaus erste psychoendokrinologische und bildgebende Studien für eine z. T. gemeinsame Pathogenese. Eine pathogenetische Spezifität einzelner ätiologischer Faktoren scheint nicht zu bestehen, die Annahme eines Diathese-Stress-Modells der BDP mit Traumatisierung als notwendige, aber nicht hinreichende ätiologische Bedingung scheint aber gerechtfertigt. Die weitere Forschung wird belegen müssen, ob die BPD als komplexe und chronisch verlaufende Form einer früh einsetzenden posttraumatischen Belastungsstörung nach multiplen und chronischen Traumatisierungen in Kindheit und/oder Jugend eingeordnet werden sollte.SummaryRegarding the high prevalence of traumatic experiences in patients with borderline personality disorders (BPD), we review the available literature focussing on the hypothesis that BPD is a subtype of trauma associated disorders. The criteria of BPD, of complex post-traumatic stress disorders (PTSD), and of disorders of extreme stress not otherwise specified (DESNOS) substantially overlap. Research of the long-term course of BPD and PTSD, trauma research, and research of vulnerability in both disorders yielded converging results. Neuropsychological deficits in BPD and PTSD as well as psychoendocrinological and neuroimaging studies in BPD und PTSD also revealed common features. A pathogenetic specificity of individual etiologic factors does not appear to exist, however the assumption of a diathesis-stress model with traumatisation as a necessary but etiologically insufficient condition seems justified. Further research will have to prove BPD as a complex and early-onset post-traumatic stress disorder after multiple and/or chronic (type II) traumatic experiences during childhood and/or youth. Definitive conclusions require further research efforts.

Neural correlates of episodic and semantic memory retrieval in borderline personality disorder: an fMRI study.

Verbal memory impairment in borderline personality disorder (BPD) is still a matter of debate. In this study we combine investigations of both, memory retrieval as well as underlying neural circuits in BPD. Functional magnetic resonance imaging (fMRI) was used to study regional brain activation in 18 right-handed female patients with BPD and 18 matched controls during the retrieval of an episodic memory retrieval (EMR) task (free recall of a word list) and a semantic memory retrieval (SMR) task (verbal fluency). Despite unaffected performance in EMR and SMR, patients with BPD showed task-specific increased activation compared with controls. During EMR, the increased activation encompassed the posterior cingulate cortex bilaterally, the left middle and superior temporal gyrus, the right inferior frontal gyrus, and the right angular gyrus. SMR was associated with increased activation of the posterior cingulate cortex, of the right fusiform gyrus, of the left anterior cingulate cortex, and of the left postcentral gyrus. Our findings suggest that BPD patients may need to engage larger brain areas to reach a level of performance in episodic and semantic retrieval tasks that is comparable to that of healthy controls.

[Is the borderline personality disorder a complex post-traumatic stress disorder? - The state of research].

ZusammenfassungAusgehend von der hohen Prävalenz traumatisierender Erfahrungen in der Vorgeschichte von PatientInnen mit Borderline-Persönlichkeitsstörung (BPD) geht diese Übersicht der Frage nach, inwieweit die BPD als eine Form traumaassoziierter Störungen aufgefasst werden kann. Außer klinisch-phänomenologischen Überschneidungen mit den Konzepten der komplexen posttraumatischen Belastungsstörung (PTSD) und der “disorders of extreme stress not otherwise specified (DESNOS)” konvergieren auch Befunde zum Langzeitverlauf und Befunde zu möglichen Vulnerabilitätsfaktoren. Unter Berücksichtigung der allgemeinen Stressforschung und ähnlicher neuropsychologischer Defizite bei BPD und PTSD sprechen darüber hinaus erste psychoendokrinologische und bildgebende Studien für eine z. T. gemeinsame Pathogenese. Eine pathogenetische Spezifität einzelner ätiologischer Faktoren scheint nicht zu bestehen, die Annahme eines Diathese-Stress-Modells der BDP mit Traumatisierung als notwendige, aber nicht hinreichende ätiologische Bedingung scheint aber gerechtfertigt. Die weitere Forschung wird belegen müssen, ob die BPD als komplexe und chronisch verlaufende Form einer früh einsetzenden posttraumatischen Belastungsstörung nach multiplen und chronischen Traumatisierungen in Kindheit und/oder Jugend eingeordnet werden sollte.SummaryRegarding the high prevalence of traumatic experiences in patients with borderline personality disorders (BPD), we review the available literature focussing on the hypothesis that BPD is a subtype of trauma associated disorders. The criteria of BPD, of complex post-traumatic stress disorders (PTSD), and of disorders of extreme stress not otherwise specified (DESNOS) substantially overlap. Research of the long-term course of BPD and PTSD, trauma research, and research of vulnerability in both disorders yielded converging results. Neuropsychological deficits in BPD and PTSD as well as psychoendocrinological and neuroimaging studies in BPD und PTSD also revealed common features. A pathogenetic specificity of individual etiologic factors does not appear to exist, however the assumption of a diathesis-stress model with traumatisation as a necessary but etiologically insufficient condition seems justified. Further research will have to prove BPD as a complex and early-onset post-traumatic stress disorder after multiple and/or chronic (type II) traumatic experiences during childhood and/or youth. Definitive conclusions require further research efforts.

Can reinforcement-based interventions to reduce drug use successfully be adapted to routine opioid maintenance treatment?

INTRODUCTION Comorbid substance related disorders are a major health problem for patients in opioid maintenance treatment (OMT). It was investigated whether a reinforcement scheme adapted to the regulatory and financial restrictions of routine treatment reduces concomitant drug use. METHODS OMT patients from 7 clinics who were using cocaine, benzodiazepines, heroin or amphetamines were randomly allocated to either treatment as usual (n = 64) or treatment with an additional escalating reinforcement scheme (n = 72) in which a patients number of weekly take-home dosages was increased after 1, 4, 8 and 12 consecutive weeks with drug-free urine specimens. Trial duration was 26 weeks. RESULTS Completion rates were 64% for controls and 62.5% in the experimental group. Mean number of drug-free weeks was 11.3 (SD 8.5) for the control group and 9.8 (8.9) for the experimental group (p = 0.30). CONCLUSION The intervention was not effective compared to routine treatment. Additional features might be necessary to achieve an effect, e.g. a higher frequency of urine sampling or use of other reinforcers. It has to be further investigated how interventions which have been proven effective in experimental studies can successfully be adapted to routine care conditions.

Community Reinforcement Approach (CRA) – Überblick über ein integratives Konzept zur Behandlung von Abhängigkeitserkrankungen

Einleitung: Der Community Reinforcement Approach (CRA) ist ein in den USA entwickeltes umfassendes verhaltenstherapeutisches Konzept zur Behandlung von substanzbezogenen S...

Ist die Borderline-Persönlichkeitsstörung eine komplexe posttraumatische Störung? Zum Stand der Forschung: Zum Stand der Forschung

ZusammenfassungAusgehend von der hohen Prävalenz traumatisierender Erfahrungen in der Vorgeschichte von PatientInnen mit Borderline-Persönlichkeitsstörung (BPD) geht diese Übersicht der Frage nach, inwieweit die BPD als eine Form traumaassoziierter Störungen aufgefasst werden kann. Außer klinisch-phänomenologischen Überschneidungen mit den Konzepten der komplexen posttraumatischen Belastungsstörung (PTSD) und der “disorders of extreme stress not otherwise specified (DESNOS)” konvergieren auch Befunde zum Langzeitverlauf und Befunde zu möglichen Vulnerabilitätsfaktoren. Unter Berücksichtigung der allgemeinen Stressforschung und ähnlicher neuropsychologischer Defizite bei BPD und PTSD sprechen darüber hinaus erste psychoendokrinologische und bildgebende Studien für eine z. T. gemeinsame Pathogenese. Eine pathogenetische Spezifität einzelner ätiologischer Faktoren scheint nicht zu bestehen, die Annahme eines Diathese-Stress-Modells der BDP mit Traumatisierung als notwendige, aber nicht hinreichende ätiologische Bedingung scheint aber gerechtfertigt. Die weitere Forschung wird belegen müssen, ob die BPD als komplexe und chronisch verlaufende Form einer früh einsetzenden posttraumatischen Belastungsstörung nach multiplen und chronischen Traumatisierungen in Kindheit und/oder Jugend eingeordnet werden sollte.SummaryRegarding the high prevalence of traumatic experiences in patients with borderline personality disorders (BPD), we review the available literature focussing on the hypothesis that BPD is a subtype of trauma associated disorders. The criteria of BPD, of complex post-traumatic stress disorders (PTSD), and of disorders of extreme stress not otherwise specified (DESNOS) substantially overlap. Research of the long-term course of BPD and PTSD, trauma research, and research of vulnerability in both disorders yielded converging results. Neuropsychological deficits in BPD and PTSD as well as psychoendocrinological and neuroimaging studies in BPD und PTSD also revealed common features. A pathogenetic specificity of individual etiologic factors does not appear to exist, however the assumption of a diathesis-stress model with traumatisation as a necessary but etiologically insufficient condition seems justified. Further research will have to prove BPD as a complex and early-onset post-traumatic stress disorder after multiple and/or chronic (type II) traumatic experiences during childhood and/or youth. Definitive conclusions require further research efforts.