Original articlePosttraumatic stress disorder and fMRI activation patterns of traumatic memory in patients with borderline personality disorder
Section snippets
Subjects
Twelve Caucasian, 21-year-old to 40-year-old, female traumatized BPD patients were included in the study. All of them were treated for BPD as inpatients in the Gilead Hospital or in the Ev. Johannes Hospital, Bielefeld, Germany, during 2001 and 2002. All patients met DSM-IV criteria of BPD, assessed by the treating psychotherapists within the first week after admission. Participants were neither pregnant nor had any of the following current or previous medical conditions, which were assessed by
Clinical assessment and memory testing
The clinical assessment was similar to that in a previous study (Driessen et al 2000), but participants completed the full Structured Clinical Interview for DSM-IV (SCID) (Wittchen et al 1997). Current psychopathology was assessed by the Beck Depression Inventory (BDI) (Beck and Steer 1994), the Symptom Checklist (SCL-90-R) (Franke 1995), and the Dissociative Experiences Scale (DES) (Bernstein and Putnam 1986; German version by Freyberger et al 1999). Traumatization history was assessed by the
Autobiographical interview and traumatic memories
The method of script-driven stimulation has been applied not only in neuroimaging studies of traumatized subjects Bremner et al., 1999a, Lanius et al., 2002, Lanius et al., 2003 but also in those of other psychiatric and neurologic conditions like addictive disorders (Kilts et al 2001) and epilepsy (Jokeit et al 2001). Basing on these experiences, we applied a semistructured autobiographical research interview Fischer-Rosenthal, 1991, Hopf, 1991, Witzel, 1985 1 week before fMRI acquisition. The
Case report
Patient 2 was sexually abused by her teacher in the hall of the residence. The key words (cues) for this traumatic episode were teacher, hall of residence, and touch. She also reported a severe sunburn with medical consequences for 2 days during a hiking tour on the island of Malta. The key words (cues) for this nontraumatic episode were sun, Malta, and hiking.
The key words were agreed upon with the patients as cue stimuli for the active recall of the episode during fMRI (cue-driven method).
Stimulus presentation and design
Structural scanning was obtained in the days before fMRI to exclude brain damage, and all technical and study details were explained. On the day of fMRI acquisition, we started the protocol with a self-rating scale (see below) before patients entered the tomograph. We chose a boxcar design with presentation of two activation conditions (trauma condition and nontrauma condition) in a between-subjects randomly balanced order and with the presentation of a baseline condition (BC). The design
MRI acquisition
Magnetic resonance imaging scanning was performed on a 1.5 Tesla scanner (Siemens Magnetom Symphony, Erlangen, Germany) equipped with a standard head coil. On the day of fMRI, scout images were obtained. Sagittal T1-weighted images were obtained in each subject, scanning to position the axial T2*-weighted images along the anterior commissure-posterior commissure (AC-PC) line. For fMRI, 16 contiguous axial T2*-weighted images covering the brain with a slice thickness of 7 mm were obtained using
Image and statistical analyses
Functional MRI data were analyzed using SPM99 (Wellcome Department of Imaging Neuroscience, London, United Kingdom; http://www.fil.ion.ucl.ac.uk/spm99, accessed September 26, 2003) for all image preprocessing and voxel-based statistical analyses within the context of the general linear model. Image realignment corrected for head movement using the SPM99 default algorithm. Spatial normalization reduced anatomical differences before group comparisons, again using default settings and the standard
Sample characteristics and traumatization history
The mean age of our sample was 32.7 ± 9.3 years, and five patients (41.7%) lived in a partnership. The mean time of education was 11.2 ± 1.6 years with five patients (41.7%) having reached a high school degree (the German “Abitur”). All patients were right-handed. There were no significant differences between the patients with and without additional current PTSD (each subgroup n = 6) with regard to comorbid psychiatric diagnoses, psychopathology, traumatization history, and prescribed
Discussion
In this fMRI study of severely traumatized women with BPD, we compared the autobiographical memory of traumatic episodes (TC) with that of aversive but nontraumatic episodes (NTC). Patients reported higher levels of anxiety, helplessness, and tactile sensations, as well as stronger feelings of unreality, in the TC compared with the NTC. Although we did not measure additional physiologic parameters (like heart rate and blood pressure), these results indicate the subjects' actual engagement in
Acknowledgements
Parts of this study were supported by the Deutsche Forschungsgemeinschaft (DFG) Grant Dr 358/5–1. We thank our patients for their readiness to engage in this study, and the Society of Epilepsy Research Bethel for providing scan time.
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