alt="Blogging on Peer-Reviewed Research"
researchers did fMRI
of brains of persons with href="http://en.wikipedia.org/wiki/Borderline_personality_disorder"
rel="tag">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
don't always pan out when larger populations are studied.
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.
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
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
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.
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 href="http://online.wsj.com/article/SB119402985846180627.html?mod=googlenews_wsj">this
article, (HT: href="http://melancholicfeminista.blogspot.com/">Aspazia)
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
Too often, the perception of risk functions as a href="http://www.overcomingbias.com/2007/08/semantic-stopsi.html">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.
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...
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).
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.