Changes in the Brain as Borderline Patients Learn to Regulate Their Emotions

Borderline Personality Disorder (BPD) is a common psychiatric disorder found in approximately
2% to 6% of the population . It is characterized by intense and rapid mood changes,
self-destructive behavior, suicidality, and tumultuous relationships. In additional to the
emotional costs of the suffering experienced by borderline patients and their loved ones, BPD
patients typically function at a level substantially below that of individuals with
comparable intellect. The difficulty controlling emotion, so central to the disorder, has
proved a particularly difficult to treat. The present study utilizes the latest neuroimaging
findings in BPD to generate new ideas for the psychotherapy of the disorder.

This project builds upon our previous neuroimaging work, which has shown that when BPD
patients try to control their emotions by employing a method that healthy people frequently
use quite effectively -- taking an emotional distance from what is upsetting - BPD patients
are not able to quiet down the part of their brain that sends out emotional alarm signals.
The objective of the present study is to determine whether giving BPD patients special
training in using this healthy distancing strategy can help them to improve their ability to
regulate their emotions and return their brain activity to a more normal pattern. The
investigators will do this by using fMRI to record brain activity as BPD subjects try to use
distancing to reduce their emotional reactions to upsetting pictures before any training,
then to have them receive specific training in the distancing strategy. After this training
we will again obtain an fMRI scan to determine whether their pattern of brain activation has
normalized and whether they have been able to better reduce their negative reactions to the
pictures. If this is effective, it will show that such training may help BPD patients better
regulate their emotions and would support a program to further develop and incorporate
distancing training into the psychotherapy of BPD patients.

A second objective of the present study is to determine whether the tendency of BPD patients
to become increasingly sensitized to negative situations when they are re-experienced (as
shown by increased activity of the brain's emotional alarm system), will reduce with
additional exposure, as it does in patients with phobias, or will continue to increase.
Knowing this can help the therapist plan how to most therapeutically approach disturbing life
experiences in the psychotherapy of BPD patients.

This project represents an important step in brain imaging research since it applies
information learned about brain activity patterns to develop new approaches to psychotherapy.
It addresses a serious, prevalent and difficult to treat disorder.

Inclusion Criteria:

- BPD subjects 18 to 50 years old

- Meet criteria for DSM-IV Borderline Personality Disorder, including the DSM-IV
criteria for affective instability (criterion #6), and not meet criteria for
Schizotypal Personality Disorder (SPD) or AvPD.

- Subjects in the AvPD group meet DSM-IV criteria for AvPD and not for BPD or SPD.

- All subjects will be free of psychotropic medications for 2 weeks (6 weeks for
fluoxetine).

- Subjects may be enrolled in psychotherapy

Exclusion Criteria:

- BPD and AvPD subjects will not meet DSM-IV criteria for past or present PTSD, bipolar
I disorder, schizophrenia, schizoaffective disorder, substance dependence, head
trauma, CNS neurological disease, seizure disorder or current major depression.

- Substance abuse disorder in the prior 6 months

- Significant medical illness

- Pregnancy

- Metallic foreign-bodies that contraindicate MRI