REVIEW ARTICLE

https://doi.org/10.5005/jp-journals-11001-0080
Eastern Journal of Psychiatry
Volume 24 | Issue 2 | Year 2024

A Review Article on Neurobiological and Psychotherapeutic Approach in Management of Borderline Personality Disorder

Jyotika

Department of Psychiatry, Silchar Medical College and Hospital, Silchar, Assam, India

Corresponding Author: Jyotika, Department of Psychiatry, Silchar Medical College and Hospital, Silchar, Assam, India, e-mail: ninijyotika@gmail.com

Received on: 20 May 2024; Accepted on: 10 October 2024; Published on: 16 November 2024

How to cite this article: Jyotika. A Review Article on Neurobiological and Psychotherapeutic Approach in Management of Borderline Personality Disorder. East J Psychiatry 2024;24(2):39-44.

Source of support: Nil

Conflict of interest: None

Keywords: Neurobiological, Psychotherapy, Symptomatology.

INTRODUCTION

Disturbed self-identity, impulsivity, interpersonal issues, and dysregulation of emotions are hallmarks of borderline personality disorder (BPD), a rather severe and complicated psychiatric illness. Altogether, five categories of traits, a borderline pattern qualifier, and a severity level make up the given ICD-11 model of personality disorder.1,2 Although affective instability is accentuated as a crucial criterion with respect to BPD in not only the DSM-53 but also ICD-11,4 BPD symptoms encompass a wide range of symptoms.

The estimated prevalence is 5.9% overall, nevertheless rising to 6.4% in primary care settings for adults. Medication is only used as an adjunct to psychotherapy, which indeed is the main treatment.2 BPD bestows difficulties not only for the patient but also for the psychiatrist. The management approach ought to be holistic and multifaceted. This review article seeks to shed light on the pathophysiology of BPD by critically analyzing published research that deals with the etiology, neurobiology, neuroimaging, and different psychotherapy treatments for BPD.

MATERILAS AND METHODS

We conducted a thorough literature analysis to gain a better understanding of BPD from several angles, including neuroscience and psychotherapy treatment, and to prove that this topic is highly relevant.

Sources for the data included PubMed, Google Scholar, MEDLINE, and the Journal of Clinical Neuroscience and Neurourology, published by the American Medical Association. Brain plasticity disorder, neuroscience, neuroimaging, and psychotherapies for BPD were the focus of extensive literature reviews. Searching the PubMed database for ”Borderline Personality Disorder” yielded 533 papers. Breaking them down further, the following topics were covered: etiopathogenesis of BPD (525 articles), ”neurobiology of BPD” (11 papers), ”neurophysiology of BPD” (2 papers), ”neuroimaging of BPD” (35 articles), ”genetics of BPD” (46 articles), and ”psychotherapies in BPD” (110 papers). By the year 2024, 1,265 peer-reviewed scientific publications have been produced from this search. Although some of the articles were duplicates, the overall number of articles was >500.

Inclusion Criteria

  • Articles were selected for this evaluation based on their relevance to the subject and the presence of keywords in either the title or abstract.

  • Cohort studies, series of cohorts, and randomized controlled trials pertaining to psychotherapies for BPD were all part of the research. For the purposes of this review, we only included publications that contained investigations conducted on humans when discussing the etiopathogenesis, neurobiology, neurophysiology, neuroimaging, or genetics of BPD. For publications published between the years 2000 and 2024, a stringent screening process was implemented.

  • Research from all across the globe was taken into account.

Exclusion Criteria

  • Research that was unrelated to the subject or keywords was not included.

  • Articles published before the year 2000 were not included.

  • Studies conducted on animals were not included.

  • An English transcript or translation was included with the majority of the articles that were chosen.

  • We did not include studies that showed ambiguity or conclusions that did not have obvious pathophysiological links with the subject or its keywords.

Ethical Issues

All data were obtained in a legitimate manner and appropriately reported. The individuals and organizations involved have their privacy protected.

DISCUSSION

Artistic Approach in Understanding of Symptomatology

Understanding the different realms of symptomatology of BPD is not only extensive but also arduous, simultaneously being subjective as well as objective. In this article, we shall proceed through a different artistic approach to understand the cognitive depths of BPD rather than using exhaustive scientific words and definitions for the same. Starting with Natalie Imbruglia’s ”Torn” (1997) and P!nk’s ”Just Like a Pill” (2001), we can hear the emotions of emptiness, emotional pain, and instability expressed through lyrics like ”I can’t stay on your life support, there’s a shortage in the switch, I can’t stay on your morphine, ’cause it’s making me itch,” which characterizes the turbulent and precarious connection, reflective of the intense and precarious interpersonal interactions. For those who suffer from BPD, the song ”Numb” by Linkin Park (2003) hits close to home. Splitting means viewing people or situations in extremes (all good or all bad). It is beautifully attributed in the song ”Black” by Pearl Jam (1991) with lyrics, ”I know someday you’ll have a beautiful life, I know you’ll be a star in somebody else’s sky, but why can’t it be mine?” showing the intense love and subsequent pain, signifying the emotional highs and lows typical of splitting. The song ”Don’t Speak” by No Doubt (1996), ”I really feel that I’m losing my best friend, I can’t believe this could be the end,” captures the sudden shift from closeness to feeling abandoned, reflecting splitting behavior in relationships. ”Lonely” by Akon (2004) describes feelings of abandonment and intense emotional pain. The lyrics ”I hurt myself today to see if I still feel, I focus on the pain, the only thing that’s real” explicitly describe self-harm to cope with emotional pain in the song ”Hurt” by Nine Inch Nails (1994). The song ”Basket Case” by Green Day (1994), with its very raw lyrics ”I went to a shrink to analyze my dreams. She says it’s lack of sex that’s bringing me down,” emphasizes the impulsive thoughts and actions related to mental distress. ”You Oughta Know” by Alanis Morissette (1995) navigates the intense anger outbursts, impulsivity, and emotional reaction through the lyrics, ”And I’m here to remind you of the mess you left when you went away. It’s not fair to deny me of the cross I bear that you gave to me.” ”Everlong” by Foo Fighters (1997) reflects a longing for connection and a sense of unreality, indicative of dissociation, through ”And I wonder if everything could ever feel this real forever, if anything could ever be this good again.” The words ”That’s me in the corner, that’s me in the spotlight, losing my religion” in R.E.M.’s (1991) ”Losing My Religion” express a feeling of alienation and disconnection, which are subjects often associated with dissociation. While Sia’s ”Breathe Me” highlights themes of vulnerability, emotional agony, and the need for support, Def Leppard’s ”Hysteria” centers on a sensation of being engulfed by passion and the need for a deeper connection with the one who triggers these intense sentiments. Finally, the lyrics of Papa Roach’s song ”Binge,” which go something like ”I binge and purge the worst, yet I love it to death, mixed emotions of a manic depressive, fading depressions yet the pressure is still present living and dying simultaneously,” highlight issues of emotional instability, impulsive behavior, and self-destructive tendencies.

Pathogenesis of Borderline Personality Disorder

Genetics and Childhood Experiences

The heredity of BPD is modest, according to Gunderson et al.’s study on family studies. The heritability of the four subtypes of BPD—affective, interpersonal, behavioral, and cognitive—is slightly lower.5 Pertaining to the absence of twin studies that investigated the whole range of personality disorders, Torgersen et al. in his study evaluating the heritability of personality disorders found it to be 69% for BPD.6 Meanwhile, Kendler et al. found lower values of total heritability at 37.1% and total environmentality at 62.9% for BPD.7

Methylation found in the location 1F promoter region located on NR3C1, as well as on intron 7 of FKBP5, which impact psychopathology and empathy, corresponds to epigenetic modification of the genes in childhood maltreatment, according to established literature. This dysregulation affecting the stress response system is, however, controlled by the hypothalamic-pituitary-adrenal (HPA) axis. While Flasbeck et al. did find a decrease in NR3C1 methylation in BPD patients compared to controls, there were only minor variations in the levels of FKBP5 methylation between the clinical and nonclinical groups. Despite his best efforts, he was unable to replicate his findings in the BPD group on the correlation between psychopathology and empathy scores, as well as the regulation of glucocorticoid receptor sensitivity through methylation of FKBP5.8

Neurobiology

Patients with BPD often encounter elevated stress hormone levels (e.g., basal cortisol) and decreased feedback sensitivity, which are associated with an increase in HPA activity and a decrease in peripheral oxytocin levels. However, insecure attachment and a history of childhood maltreatment are the primary factors in the development of BPD.9,11 Research has shown that the oxytocinergic system may regulate the dysfunctional patterns of self-other and interpersonal behaviors.12 Interestingly, several studies have shown that testosterone levels might actually rise in BPD patients.10 In addition, core neural network abnormalities in BPD have been conceptualized as affecting not only the top-down control system, which is regulated by the orbitofrontal cortex and the anterior cingulate cortex, providing cognitive control, but also the bottom-up control system, which is generated in the limbic system and includes the amygdala, hippocampus, and insular cortex, allowing for salience detection.13 A key feature of BPD is impulsivity, which corresponds to the reward and control circuits as well as deficient behavioral inhibition based in prefrontal areas. Serotonin, the principal neurotransmitter involved, regulates these regions. Specifically, an increase in 5-HT2A receptors and a decrease in 5-HT2C receptors are associated with impulsivity.13-15 Furthermore, maladaptive top-down processes in assessing negative environmental cues are linked to the amygdala’s function, which is associated with strong and variable emotions.16

Neuroimaging

Case studies have shown that the medial temporal lobe, hippocampus, and amygdala all shrink on both sides.17,18 Additionally, unmedicated individuals with acute BPD show hyperactivity in the left amygdala.19 The discovery of smaller amygdala gray matter volumes in older BPD patients, however, was thought to indicate a progressive but reversible disease.20 Hypoactivity in the orbitofrontal cortex, ventrolateral cortex, and dorsal anterior cingulate cortex (ACC) was inferred in a study with BPD patients in comparison to healthy individuals.21 This hypoactivity is associated with maladaptive emotional regulation in BPD patients. Psychotherapy was shown to normalize reduced prefronto-limbic connection within the circuitry that regulates emotions.22 Another study that looked at brain activity after TFP discovered that frontolimbic neural pathways were associated with better emotional and behavioral control. Both improved constraint and improved affective lability were associated with increased activation in the left posterior-medial orbitofrontal cortex/ventral striatum and decreased activation in the right amygdala/parahippocampal cortex, respectively. The hypoactivation of the right amygdala/parahippocampal cortex before treatment served as a predictor for the corresponding symptomatology.23 Additionally, compared to healthy controls, young people with BPD had a decrease in gray matter volume (GMV) in the prefrontal cortex, namely the inferior and superior frontal gyri, the medial temporal network, and the insula.24

Psychotherapies in Borderline Personality Disorder

Dialectical Behavior Therapy (DBT)

The study conducted by McMain et al. supported the noninferiority of the 6-month DBT treatment duration compared to the 12-month DBT duration for not only general psychopathology but also coping skills, even at 24 months, as well as more rapid reductions in symptoms and general psychopathology with the 6-month treatment.25 Bedics et al. compared DBT with community treatment by experts (CTBE), focusing on therapeutic relationships, introject changes, and treatment outcomes over a 2-year period for diagnosed BPD. They observed that over time, DBT therapists were seen as more affirming, protective, and less controlling but maintained an overall affiliative stance, whereas CTBE therapists were generally warm and autonomous, with a shift toward more control as treatment approached termination. DBT patients reported not only significant increases in self-affirmation, self-love, and self-protection but also decreases in self-attack during treatment and follow-up, associated with fewer nonsuicidal self-injury (NSSI) occurrences compared to CTBE patients, supporting their hypothesis that DBT impacts both symptomatic and intrapsychic changes.26 Experiment two confirmed the positive effects of both treatments on all outcomes, including avoiding unpleasant experiences, anger, anxiety, humiliation, and guilt. Nevertheless, DBT had distinct results in lowering rage expression and experiencing avoidance, which may be attributable to its emphasis on lowering emotional repression and avoidance while instructing patients to competently feel and express unpleasant emotions.27 A year of therapy significantly reduced BPD traits, including emotional instability, identity difficulties, poor relationships, and self-harm, according to Stepp et al., who studied the effects of DBT skills on BPD features. The research also discovered that people used their skills more often as time went on; the most used skills were mindfulness, then distress tolerance, emotion management, and interpersonal effectiveness.28 Based on the available literature and the results of several studies, dialectical behavior therapy (DBT) is the gold standard for treating BPD.

Cognitive Behavior Therapy (CBT)

The Borderline Personality Disorder Study of Cognitive Therapy (BOSCOT) trial conducted by Davidson et al., examining the impact of CBT combined with Treatment as Usual (TAU) vs TAU alone for 106 individuals diagnosed with BPD over 27 sessions, with 16 on average, demonstrated that the global odds ratio for the combined occurrence of suicidal acts, inpatient hospitalization, or A&E contact was 0.86, indicating no significant reduction with CBT plus TAU compared to TAU alone. There was a significant decrease in the number of suicidal acts with CBT plus TAU (mean difference of −0.91). At 1 year, both groups showed gradual and consistent improvement. However, at two years, there were notable gains with CBT in terms of state anxiety, dysfunctional beliefs, and suicidal behaviors, in addition to the positive symptom distress index.29 So, unlike other mental illnesses like depression and anxiety, CBT is not a one-size-fits-all solution for BPD.

Mentalization

As a result of no difference in the outcomes when evaluating BPD symptoms, including magnitude of functioning, quality of life, global functioning, and severe self-harm between the two groups, Juul et al. inferred that long-term Mentalization-based Therapy (MBT) was not better than short-term MBT for BPD. The study lasted for fourteen months. Nevertheless, the difference in the number of significant adverse events between the two groups, long-term and short-term MBT, was mainly due to differences in the number of mental hospitalizations.30 To conclude, MBT is categorized under the recent wave of psychotherapies; however, its universal effectiveness in psychiatric disorders such as anxiety, personality disorders, depression, and stress reactions is still under research, with no major conclusiveness documented yet.

Schema-based therapy

The study by Arntz et al. compared three types of treatment for BPD: group schema therapy (PGST), individual and group schema therapy (IGST), and treatment as usual (TAU). The main outcome was a decrease in BPD severity, and secondary outcomes included measuring functioning and well-being in various ways. Moreover, the results demonstrated that IGST was a safe, effective, and acceptable therapy for BPD, accompanied by fewer suicide attempts and fewer treatment dropouts than PGST and TAU. Nevertheless, PGST did not outperform TAU. The study also found significant time effects for most outcomes over the 3-year period.31 Moreover, Klein et al. in his study evaluated the effectiveness and safety of an internet-based self-management intervention (SMI) over a 12-month duration, deploying 204 individuals with BPD when used alongside standard care (CAU) based on schema therapy. He demonstrated the intervention to be safe but found no significant change in the BPD Severity Index (BPDSI) score between the two groups. Moreover, within-group effect sizes were large for both groups. However, between-group effect sizes were small (d = 0.27 for intention-to-treat, d = 0.39 for per-protocol), thus disfavoring the internet-based intervention over CAU alone.32 Schema based therapy are an effective treatment for BPD primarily because of it targets deep-rooted patterns (schemas) that drive emotional instability, helping patients replace maladaptive beliefs with healthier coping mechanisms.

Miscellaneous

The effectiveness of a two-session imagery rescripting (IR) intervention for emotion dysregulation behavior (EDB) in female patients diagnosed with BPD was investigated in a study by Sosic-Vasic et al. The study was based on the hypothesis that modulating neural pathways by scripting negative mental images and practicing positive ones every day could alleviate emotional distress linked to these images. Furthermore, at the 3-month follow-up, not only the control group but also the experimental group showed statistically prominent improvements in impulsivity, depressiveness, inappropriate emotion regulation, as well as the severity of BPD symptoms in comparison to the control group. These findings were indicative that the treatment might be used either in conjunction with traditional psychotherapy or on its own, especially in cases where there are few alternatives for long-term treatment.33 The effectiveness of interpersonal psychotherapy (IPT) in groups (IPT-G) and individuals (IPT-BPD-R) as compared to IPT-BPD-R alone was conducted by Bozzatello et al. Improvements in both within-subjects effects (duration) and between-subjects effects (treatment modalities) were shown in the research. Specifically, items measuring work, sleep, food, and free time, as well as domineering/controlling traits as measured on the IIP-32 and the RMET, were found to improve. Additionally, it was found through multiple regression analysis that individuals with lower levels of impulsivity, better social cognition (RMET), and less socially inhibited interpersonal style (IIP-32) had more significant improvements in core BPD symptoms, social cognition, dysfunctional interpersonal styles, and quality of life after integrating group therapy into individual psychotherapy for BPD.1 Using the Zanarini rating scale for borderline personality disorder (ZAN-BPD) and amygdala neurofeedback as an intervention over the course of four sessions, Zaehringer et al. found that 24 female patients with BPD were able to successfully downregulate their amygdala blood oxygen-dependent (BOLD) response. In addition, there was a reduction in the variability of negative affect and inner tension from hour to hour, and there was an improvement in emotion regulation as shown by decreased emotion-modulated startle responses to negative images. Although neurofeedback showed some short-term improvement in addressing emotion dysregulation, the results did not continue at the 6-week follow-up, indicating that the method is only helpful in the short term. Reyes-Lopez et al. demonstrated the efficacy of repetitive transcranial magnetic stimulation (rTMS) in the treatment of 29 patients with BPD. One group received 1 Hz rTMS over the right dorsolateral prefrontal cortex (DLPFC), while the other group received 5 Hz rTMS over the left DLPFC. All groups underwent 15 sessions of rTMS. The results showed that both groups’ symptoms and severity of BPD improved globally, especially in impulsiveness, affective instability, and anger, as measured by five different standard evaluation scales. This suggests that rTMS may be an effective treatment for BPD.34 Schulze et al. looked at the possibility that transcranial direct current stimulation (tDCS) of the right dorsolateral prefrontal cortex (dlPFC) could help people with BPD better control their thoughts when faced with negative stimuli. They found that people with BPD performed worse on working memory tasks when negative distractions were present compared to a control group. The lack of improvement in cognitive control over negative stimuli in BPD patients after excitatory stimulation of the right dlPFC raises questions regarding the specific neurobiological basis of BPD and suggests that the right dlPFC may not play a significant role in modulating cognitive control of negative stimuli in BPD. However, the results highlight the difficulties in creating effective neuromodulation therapies for BPD by highlighting the complex link between prefrontal brain activity and emotional control in this condition.35 Last but not least, an effective early therapy for lowering the severity of BPD symptoms for up to one year was indicated by Zanarini et al. in their research conclusion: web-based psychoeducation.36 In order to treat BPD, not only does a therapist need to invest a great deal of time, energy, and patience, but so must the patient, their family, and even friends. A person’s psychopathology, the intensity of their symptoms, and the suffering they and those around them endure as a result of their disease should inform their management decisions; no one therapy will work for everyone. To sum up, the aforementioned psychotherapies are helpful in treating BPD, and they may be used alone or in combination with dialectical behavior therapy (DBT).

Limitations

Despite the extensive research, the results of the studies must be elucidated cautiously due to methodological considerations.29 Furthermore, the heterogeneous trial population, missing data, and deviations due to COVID-1930 may have accounted for digressions from the result. It is suggested that future larger trials with broader inclusion criteria32 must be employed for adequate and generalizable results. Neurofeedback may help with emotion regulation in BPD, in accordance with another research; however, the study lacked a control group, thus its findings were restricted.37 Data that was absent or assumed to be missing at random was also present in another mixed-model research. We must proceed with caution when interpreting findings centered on the three main emotions (angst, fear, and sadness) since it is not possible to rule out the possibility that data is not absent at random. In order to develop more effective treatments, future studies should focus on BPD-specific feelings such as isolation, shame, or abandonment anxiety. Because no psychotherapy was provided to the control group (TAU) and because the study exclusively included female patients, the results cannot be applied to males in general.33

CONCLUSION

The evidence reviewed indicates that no single treatment modality is universally effective. However, a combination of therapies, tailored to the specific psychopathology and severity of symptoms, may demonstrate a relative advantage. The assortment of psychotherapies, including DBT, CBT, MBT, and Schema Therapy, illustrates effectiveness across a considerable range in managing BPD symptomatology. DBT continues to exhibit superlative treatment, particularly in abating self-harm and improving emotional regulation. Moreover, CBT, although not as exclusively effective for BPD in comparison to other psychiatric disorders, contributes notable benefits when amalgamated with other therapies. MBT and Schema Therapy offer propitious results, particularly when considering the intricate relationship between prefrontal cortex activity and emotional regulation. Neuromodulation techniques involving rTMS and tDCS, although embryonic, attenuate the potential for neurobiological interventions, thus further research is required to solidify their respective roles. The exploration of neurofeedback techniques for emotional regulation, as well as the employment of web-based psychoeducation, yields innovative avenues for further advancement. Thus, the management of BPD warrants cumulative collaboration among the psychiatrist, psychologist, patient, family, and occasionally friends, with the indispensable utilization of time, effort, and patience, ultimately leading to personalized treatment plans to address the unique psychopathology of each patient. In conclusion, the integration of several psychotherapies, focusing on psychopathology, as well as neuromodulation treatments concentrating on investigated neural networks, may deliver an accelerated, holistic, and novel approach. Future research is mandated with an authentic focus on large-scale, intricate, inclusive trials with adequate demographic representation for generalizable and practical treatment modalities for BPD.

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