One Year of Outpatient Dialectical Behavioral Therapy and Its Impact on Neuronal Correlates of Attachment Representation in Patients with Borderline Personality Disorder Using a Personalized fMRI Task.

(1) Background: BPD is characterized by affect dysregulation, interpersonal problems, and disturbances in attachment, but neuroimaging studies investigating attachment representations in BPD are rare. No study has examined longitudinal neural changes associated with interventions targeting these impairments. (2) Methods: We aimed to address this gap by performing a longitudinal neuroimaging study on n = 26 patients with BPD treated with Dialectic Behavioral Therapy (DBT) and n = 26 matched healthy controls (HCs; post intervention point: n = 18 BPD and n = 23 HCs). For functional imaging, we applied an attachment paradigm presenting attachment related scenes represented in drawings paired with related neutral or personalized sentences from one's own attachment narratives. In a prior cross-sectional investigation, we identified increased fMRI-activation in the human attachment network, in areas related to fear response and the conflict monitoring network in BPD patients. These were especially evident for scenes from the context of loneliness (monadic pictures paired with individual narrative sentences). Here, we tested whether these correlates of attachment representation show a near-to-normal development over one year of DBT intervention. In addition, we were interested in possible associations between fMRI-activation in these regions-of-interest (ROI) and clinical scores. (3) Results: Patients improved clinically, showing decreased symptoms of borderline personality organization (BPI) and increased self-directedness (Temperament and Character Inventory, TCI) over treatment. fMRI-activation was increased in the anterior medial cingulate cortex (aMCC) and left amygdala in BPD patients at baseline which was absent after intervention. When investigating associations between scores (BPI, TCI) and functional activation, we found significant effects in the bilateral amygdala. In contrast, aMCC activation at baseline was negatively associated with treatment outcome, indicating less effective treatment effects for those with higher aMCC activation at baseline. (4) Conclusions: Monadic attachment scenes with personalized sentences presented in an fMRI setup are capable of identifying increased activation magnitude in BPD. After successful DBT treatment, these increased activations tend to normalize which could be interpreted as signs of a better capability to regulate intensive emotions in the context of "social pain" towards a more organized/secure attachment representation. Amygdala activation, however, indicates high correlations with pre-treatment scores; activation in the aMCC is predictive for treatment gain. Functional activation of the amygdala and the aMCC as a response to attachment scenes representing loneness at baseline might be relevant influencing factors for DBT-intervention outcomes.

Secure Attachment Representation in Adolescence Buffers Heart-Rate Reactivity in Response to Attachment-Related Stressors.

To date, we know very little about the effects of the differences in attachment classifications on the physiological correlates of stress regulation in adolescent age groups. The present study examined for the first time heart rate (HR) and heart rate variability (HRV) during an attachment interview in adolescents. HR and HRV data were collected during a baseline assessment as well as during the administration of the Adult Attachment Projective Picture System (AAP) in a community-based sample of 56 adolescents (26 females and 30 males, mean age = 16.05 years [SD = 1.10]). We additionally used the Adult Attachment Interview (AAI) in 50% of our sample to test the convergent validity. Adolescents with a secure attachment representation showed a higher HRV from baseline to the AAP interview compared to those with an insecure-dismissing (Ds) and the unresolved group. A comparison between the two insecure attachment groups showed no significant difference related to HR and HRV. Cohen's Kappa (κ = 0.81) revealed an almost perfect agreement between the AAP and the AAI for the four-group classification. Our results indicate that adolescents with a secure attachment representation are more capable of dealing with attachment-related distress which is represented in higher HRV during an attachment interview.

Neural Correlates of Attachment Representation in Patients With Borderline Personality Disorder Using a Personalized Functional Magnet Resonance Imaging Task.

Background: Fear of abandonment and aloneness play a key role in the clinical understanding interpersonal and attachment-specific problems in patients with borderline personality disorder (BPD) and has been investigated in previous functional Magnet Resonance Imaging (fMRI) studies. The aim of the present study was to examine how different aspects of attachment representations are processed in BPD, by using for the first time an fMRI attachment paradigm including personalized core sentences from the participants' own attachment stories. We hypothesized that BPD patients would show increased functional involvement of limbic brain regions associated with fear and pain (e.g., the amygdala and the anterior cingulate cortex) when presented personalized attachment relevant stimuli representing loneliness compared to healthy controls (HC). Methods: We examined the attachment classifications of 26 female BPD patients and 26 female HC using the Adult Attachment Projective Picture System (AAP). We used an fMRI-adapted attachment paradigm to investigate the neural correlates of attachment. All participants were presented three personalized (vs. neutral) sentences extracted from their AAP attachment narrative, combined with standardized AAP pictures representing being alone (monadic) or in interactive (dyadic) attachment situations. Results: As expected, the classification of unresolved attachment was significantly greater in BPD compared to HC. BPD patients showed increased fMRI-activation in brain areas associated with fear, pain, and hyperarousal than HC when presented with personalized attachment-relevant alone stimuli. In particular, pictures with monadic attachment situations induced greater anterior medial cingulate cortex, anterior insula, amygdala, thalamus and superior temporal gyrus activation in the patient group. Conclusion: The results point to increased fMRI-activation in areas processing emotional distress and painful experiences in BPD patients. In particular, the emotional cascade reflecting attachment distress was evoked by combining monadic pictures, representing abandonment and aloneness, with the patients' personalized narrative material. Our results confirmed and replicated previous results that illustrate once again the high relevance of aloneness and feelings of abandonment for BPD in the context of attachment trauma. Moreover, our results support the hypothesis of hypermentalization in response to attachment distress as a core feature of social-cognitive impairment in BPD associated with common treatment implications across different therapeutic orientations.

The Change in Parental Symptoms and Dysfunctional Cognitions in the Course of Trauma-Focused Cognitive-Behavioral Therapy: Sustainability Until One-Year Post-Treatment.

Objectives: Symptoms of distress and dysfunctional posttraumatic cognitions (PTCs) have been frequently described in parents of children and adolescents with posttraumatic stress symptoms (PTSS), especially if the parents had experienced traumatic events themselves. The inclusion of non-offending parents in trauma-focused cognitive-behavioral therapy (TF-CBT) for children and adolescents may, thus, help parents to cope with the traumatic experience of their child. The aim of this study is to investigate the effects of TF-CBT on the parents, while taking their own history of traumatic experiences into account. Methods: Parents (N = 57, 84.2% mothers) of children and adolescents who received TF-CBT completed the Posttraumatic Diagnostic Scale, the Beck Depression Inventory, the State-Trait Anxiety Inventory, and the Posttraumatic Cognitions Inventory. Treatment effects and the sustainability at 6- and 12 months post-treatment were tested via repeated-measures analysis of variance, following the intention-to-treat approach. Results:N = 19 (35.2%) of the parents evaluated their child's trauma as the worst event, 18 (33.3%) rated their own experience as their worst event, and 17 (31.5%) indicated that their own worst traumatic experience was the same type as their child's trauma. Significant improvements (p < 0.001) emerged for parental PTSS [F(2, 837) = 8.27; d = 0.30], depression [F(3, 284) = 14.73; d = 0.41], anxiety symptoms [F(3, 185) = 17.44; d = 0.64], and dysfunctional PTCs [F(2, 465) = 13.58; d = 0.46]. Sustainability of these treatment gains remained at both follow-up time points (p < 0.05). There was no interaction between the time and the reference person of the traumatic index event, reported by parents. Conclusion: These results indicate parental benefits from participation in TF-CBT delivered to their child, until 1-year post-treatment and independently from the parental trauma history. The ongoing tendency of improvement might indicate that TF-CBT furnishes children and their parents with skills to further reduce the impact of their traumatic memories. ClinicalTrials.gov NCT01516827.

The role of attachment characteristics in dialectical behavior therapy for patients with borderline personality disorder.

Attachment characteristics play a key role in understanding borderline-specific problems with respect to childhood maltreatment. The aim of this study was to investigate how attachment representations may influence the trajectory of change in a 1-year outpatient dialectical behavior therapy (DBT) for patients with borderline personality disorder (BPD). Attachment representations were assessed in 26 BPD patients and 26 healthy controls (HC) using the Adult Attachment Projective Picture System (AAP) before treatment. Borderline and global symptom severity and interpersonal problems were examined before, during, and after completing the intervention. Analysis of variance and stepwise hierarchical regression analyses were used to explore the course of symptomatology. As expected, BPD patients displayed a predominance of unresolved attachment in the AAP compared with HC, by showing a lack of ability to integrate attachment related trauma. Whereas both resolved and unresolved attachment groups revealed significant improvement in symptom severity during treatment, dimensional AAP scores showed differences. Patients with higher scores in "synchrony" demonstrated more indicators of mutual care in their narratives to dyadic pictures and displayed a significantly stronger decrease of interpersonal problems than patients with lower synchrony scores. Assessing attachment representations prior to DBT might provide a helpful insight into individual attachment related resources or lack of these capacities. Responsiveness and synchrony in dyadic interactions with significant others are crucial for healthy interpersonal relations. A stronger therapeutic focus on the patient's capacity to show synchrony in dyadic attachment situations might improve the patient's interpersonal problems towards sensitive and mutual interaction.

Structural Alterations in the Corpus Callosum Are Associated with Suicidal Behavior in Women with Borderline Personality Disorder.

Structural alterations in the corpus callosum (CC), the major white matter tract connecting functionally related brain regions in the two hemispheres, have been shown to be associated with emotional instability, impulsivity and suicidality in various mental disorders. To explore whether structural alterations of the CC would be similarly associated with emotional instability, impulsivity and suicidality in borderline personality disorder (BPD), we used diffusion tensor imaging (DTI) to assess the structural integrity of the CC in 21 BPD and 20 healthy control (HC) participants. Our hypothesis-driven analyses revealed a positive correlation between BPD participants' suicidal behavior and fractional anisotropy (FA) in the splenium and genu of the CC and a negative correlation between BPD participants' suicidal behavior and mean diffusivity (MD) in the splenium of CC. Our exploratory analyses suggested that suicidal BPD participants showed less FA and more MD in these regions than HC participants but that non-suicidal BPD participants showed similar FA and MD in these regions as HC participants. Taken together, our findings suggest an association between BPD participants' suicidal behavior and structural alterations in regions of the CC that are connected with brain regions implicated in emotion regulation and impulse control. Structural alterations of the CC may, thus, account for deficits in emotion regulation and impulse control that lead to suicidal behavior in BPD. However, these findings should be considered as preliminary until replicated and extended in future studies that comprise larger samples of suicidal and non-suicidal BPD participants.

[Influence and Change of Self-Directedness in Dialectical Behavior Therapy]. / Einfluss und Veränderung der Selbstlenkungsfähigkeit in der Dialektisch-Behavioralen Therapie (DBT).

Objective Investigate influence and change of self-directedness (SD) in Dialectical-Behavior Therapy (DBT) for 26 female outpatients with borderline personality disorder (BPS). Method Variance analyses are used to evaluate psychopathology and interpersonal problems in 2 subgroups (low vs. high SD) with questionnaires at 3 measuring times over the period of 1 year. Results Low SD was associated with higher psychopathology, more interpersonal problems and lower symptomreduction. Over time of intervention the SD of all patients improved significantly. Conclusion DBT strengthens the SD of patients with BPD. A screening of SD before intervention, and systematic support should be considered.

[Results of an outpatient intervention for obese children and adolescents]. / Ergebnisse einer ambulanten Interventionsstudie bei adipösen Kindern und Jugendlichen.

BACKGROUND: Aim of this study was to examine effects of an outpatient intervention program for obese children. METHOD: 45 obese children were treated with a cognitive-behavioural intervention program (IG) and were compared with 21 children of a waiting list (WG). Weight, self esteem, emotional and behaviour problems were measured at the beginning (T0) and the end (of T1) of the intervention. Additionally, predictors of therapy success were examined. RESULTS: The intervention program lead to a moderate reduction of weight, whereas there was no weight reduction in the waiting group. Furthermore, self esteem increased and emotional problems decreased in the IG. Neither a positive family history of obesity nor the weight at T0 did predict treatment outcome. CONCLUSION: Obese children profited from the cognitive-behavioral intervention program, weight reduction was, however, only moderate. Therefore, specific predictors for therapy success should be evaluated in further studies.

[Obesity in childhood and adolescence--first results of a multimodal intervention study in Mecklenburg-Vorpommern]. / Adipositas im Kindes- und Jugendalter--Erste Ergebnisse einer multimodalen Interventionsstudie in Mecklenburg-Vorpommern.

The prevalence of obesity in children and young adults in Germany has dramatically increased during the last decades. We investigated the impact of an one year outpatient intervention including physical training, psychotherapy and nutrition counselling on psychological status and course of weight of 19 adolescents who were diagnosed with obesity (intervention group, IG). The following questions were of particular interest: Is there a difference between children with obesity (n = 19, mean age 12.4 years) and controls (without obesity and overweight, control group, CG, n = 38, matched for age and sex) regarding the extent of emotional and behavioural problems, self-esteem and physical complaints? Does the intervention lead to a decrease of these problems as rated by the adolescents and mothers? Can we find a significant reduction of the BMI-SDS after one year training in the IG? The group comparisons between the IG and the CG revealed lower feelings of self-esteem, more self rated physical complaints, higher values on measures of depression/anxiety and attention problems in the CBCL for children with obesity, compared with controls. After one year training adolescents' psychological well being increased significantly while the BMI-SDS only decreased moderately. We conclude that children with obesity can benefit from receiving outpatient intervention if psychological and medical aspects are considered.