Assessing the marks of change: how psychotherapy alters the brain structure in women with borderline personality disorder

Assessing the marks of change: how psychotherapy alters the brain structure in women with borderline personality disorder

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J Psychiatry Neurosci 2018;43(3):171-181

Falk Mancke, MD; Ruth Schmitt, PhD; Dorina Winter, PhD; Inga Niedtfeld, PhD; Sabine C. Herpertz, MD;* Christian Schmahl, MD*


Background: There is increasing evidence that psychotherapy can alter the function of the brain of patients with borderline personality disorder (BPD). However, it is not known whether psychotherapy can also modify the brain structure of patients with BPD.

Methods: We used structural MRI data of female patients with BPD before and after participation in 12 weeks of residential dialectical behavioural therapy (DBT) and compared them to data from female patients with BPD who received treatment as usual (TAU). We applied voxel-based morphometry to study voxel-wise changes in grey matter volume over time.

Results: We included 31 patients in the DBT group and 17 in the TAU group. Patients receiving DBT showed an increase of grey matter volume in the anterior cingulate cortex, inferior frontal gyrus and superior temporal gyrus together with an alteration of grey matter volume in the angular gyrus and supramarginal gyrus compared with patients receiving TAU. Furthermore, therapy response correlated with increase of grey matter volume in the angular gyrus.

Limitations: Only women were investigated, and groups differed in size, medication (controlled for) and intensity of the treatment condition.

Conclusion: We found that DBT increased grey matter volume of brain regions that are critically implicated in emotion regulation and higher-order functions, such as mentalizing. The role of the angular gyrus for treatment response may reside in its cross-modal integrative function. These findings enhance our understanding of psychotherapy mechanisms of change and may foster the development of neurobiologically informed therapeutic interventions.

*These authors contributed equally to this work.

Submitted July 13, 2017; Revised Sept. 19, 2017; Accepted Sept. 19, 2017; Published online first Dec. 13, 2017

Acknowledgements: This study was supported by grants from the German Research Foundation (DFG) awarded to S. Herpertz (HE 2660/7-2) and C. Schmahl (SCHM 1526/8-2).

Affiliations: From the Department of General Psychiatry, Center for Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany (Mancke, Herpertz); the Center for Mental Health, Odenwald District Healthcare Center, Erbach, Germany (Schmitt); the Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany (Winter, Niedtfeld, Schmahl); the Department of Clinical Psychology and Psychotherapy, University of Koblenz-Landau, Germany (Winter); and the Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, Ont., Canada (Schmahl).

Competing interests: None declared.

Contributors: S. Herpertz and C. Schmahl designed the study. R. Schmitt, D. Winter and I. Niedfeld acquired the data, which F. Mancke, I. Niedtfeld, S. Herpertz and C. Schmahl analyzed. F. Mancke wrote the article, which all authors reviewed. All authors approved the final version to be published and can certify that no other individuals not listed as authors have made substantial contributions to the paper.

DOI: 10.1503/jpn.170132

Correspondence to: F. Mancke, Department of General Psychiatry, University of Heidelberg, Voßstraße 2, 69115 Heidelberg, Germany;