Improved emotion regulation after neurofeedback. A single-arm trial in patients with borderline personality disorder

Real-time functional magnetic resonance imaging neurofeedback training of amygdala hemodynamic activity directly targets a neurobiological mechanism, which contributes to emotion regulation problems in borderline personality disorder (BPD). However, it remains unknown which outcome measures are suited to assess changes in emotion regulation and affective instability associated with amygdala down-regulation in a clinical trial. The current study directly addresses this question. 24 female patients with a DSM-IV BPD diagnosis underwent a four-session amygdala neurofeedback training. Before and after the training as well as at a six weeks follow-up, participants completed measures of emotion dysregulation and affective instability at diverse levels of analysis (verbal report, clinical interview, ecological momentary assessment, emotion-modulated startle, heart rate variability and fMRI). Participants were able to down-regulate their amygdala BOLD response with neurofeedback. There was a decrease of BPD symptoms as assessed with the Zanarini rating Scale for BPD (ZAN-BPD). Patients also indicated less affective instability, indicated by lower hour-to-hour variability in negative affect and inner tension in daily life. After training, patients showed decreased emotion-modulated startle to negative pictures. Overall, we observed changes in emotion regulation and affective instability on several systems levels, including behavior and verbal report. Conclusions are limited due to the lack of a control group. In a next step, a randomized controlled trial (RCT) is needed to confirm effectiveness of the training.