The
researchers did fMRI
of brains of persons with Borderline Personality Disorder, before
and after psychotherapy. This was a small study, using a
design that would be difficult to use routinely, but it is
provisionally interesting. Difficult, because the patients
received 12 weeks of inpatient therapy (perhaps routine in Germany;
nearly impossible in the USA). Provisional, because these
things
don't always pan out when larger populations are studied. Effects of dialectic-behavioral-therapy on the neural correlates of affective hyperarousal in borderline personality disorder
Knut Schnell and Sabine C. Herpertz
J Psychiatr Res. 2007 Nov;41(10):837-47.
doi:10.1016/j.jpsychires.2006.08.011
Abstract
Background
Affective hyperarousal is the hallmark of borderline personality disorder (BPD) and the main target for dialectic-behavioral-therapy (DBT). This pilot study examined whether improved regulation of affective arousal following DBT translates into changes in relevant neural systems.
Methods
We applied five sequential fMRI scans over a 12-week in-patient treatment program. Six female BPD patients and six controls were included in an event-related fMRI design which induced emotional arousal through standardized images. In addition to analyzing valence-based stimulus categories over time, the study assessed the modulation of hemodynamic responses through emotional arousal by means of parametric HRF modulation with self-ratings of stimulus dependent arousal.
Results
BPD data revealed a decreasing hemodynamic response to negative stimuli in the right-sided anterior cingulate, temporal and posterior cingulate cortices as well as in the left insula. In addition, these areas displayed a continuous decrease in HRF modulation through individual arousal in BPD patients. Moreover the four DBT responders displayed reduction of HRF modulation in the left amygdala and both hippocampi.
Conclusions
fMRI designs that use multiple repeated measures are suitable for application in therapy research. In our pilot study DBT treatment was accompanied by neural changes in limbic and cortical regions resembling those reported on psychotherapy effects in other mental disorders.
First of all, they state that four of the six patients responded to treatment. That is an impressive response rate, so much so, that it makes me wonder how well the population represents a general clinical population. Plus, as I mentioned, it is very difficult to provide that much treatment, at that level of intensity, here in the USA. The study design also tells us nothing about how enduring the changes will be, speaking of either the clinical improvement, or the changes in the hemodynamic response function.
Of course, this was a preclinical study, meaning that it was not intended to be applicable directly to clinical practice. I don't mean the comments above to be criticisms; rather, I want to point caution people to not read too much into the study.
Although it is difficult to draw sweeping conclusions from one small study, it is important to note that the results fit in with a body of evidence that psychotherapy, along with other non-chemical treatments, alters the brain.
This should not be surprising, but it always is better to have the evidence when trying to formulate a conclusion. Of course psychotherapy changes the brain. It would not be much good if it did not change anything, and the brain is a good place to start. Changing some other organ, say the liver, would not be as likely to be helpful in someone with a personality disorder.
Another thing this kind of study underlines, is how questionable it is to divide emotional/behavioral problems into psychological and biological categories, or Axis I vs Axis II categories. It is accurate to say that these distinctions tell you more about the divisions within the field of psychiatry, as opposed to informing us about what happens in nature.
I am faintly hopeful that, as these studies progress, and the common perception of mental illness changes, we will see changes in how people think about treatment for mental illness. Specifically, I am thinking about this article, (HT: Aspazia) and this one.
There is still some antipsychiatry sentiment out there, and often it is unduly focused on the psychopharmacological interventions. Much of it is foolish. The fact is, all interventions change the brain, and all intervention carries risk. Of course, ignoring the problem carries risk, and there is risk to identifying the problem and then deliberately choosing to not intervene.
Too often, the perception of risk functions as a cognitive stop sign: "Oh, that is risky. No need to consider it any more." Such a conclusion might be reasonable, if a risk-free path were available.
So, getting back to the study, we see evidence that psychotherapy changes the brain. Furthermore, it changes parts of the brain that are related to the symptoms of the disorder under investigation. It does not tell us what the origin of the problem is, but it narrows the search somewhat. It does not tell us how psychotherapy works, but it provides some clues.
Brain & Behavior
Medicine & Health
Comments
One can only wish that this would stop the direct-to-consumer ads from claiming that depression (for example) is "caused by a chemical imbalance"; even if there is a chemical imbalance (so far there is no biological marker that I am aware of that can distinguish "real" depression from a false positive) involved in depression, this study is yet another that shows that this chemical imbalance could be every bit as much caused as causal.
Of course, I can think of millions of reasons to keep running such ads...
Posted by: Anon | November 6, 2007 9:03 AM
Check out the work at Baylor/Menninger Clinic/UCLondon/Yale (Peter Fonagy, Jon Allen, Efrain Bleiberg, Linda Mayes) for more data-mentalization and reflective functioning. Yes, evidence based.
Although expensive unless one has amazing insurance (rare but it happens) treatment at the Menninger Clinic can last 12 weeks (more like 6-8).
Posted by: Spelling Police | February 25, 2008 2:18 PM
I'd be grateful to Corpus Callosum or others for a rigorous and validated measure of 'affective hyperarousal'preferably as defined in the above study.A recurring problem in psychiatry(as well as other disciplines to be fair)is the paucity of established and validated objective measures (of emotional states in this case)that may be open to various interpretations.
Posted by: Sumant Rawat | June 10, 2008 6:17 PM