Generic placeholder image

Current Psychiatry Research and Reviews

Editor-in-Chief

ISSN (Print): 2666-0822
ISSN (Online): 2666-0830

Systematic Review Article

A Narrative Systematic Review of the Effectiveness of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment and Management of Borderline Personality Disorder

Author(s): Georgios Kafas* and Katja Umla-Runge

Volume 20, Issue 2, 2024

Published on: 14 February, 2023

Page: [135 - 151] Pages: 17

DOI: 10.2174/2666082219666230120104856

Price: $65

Abstract

Background: Borderline Personality Disorder (BPD) is a psychiatric condition that affects approximately 2% of the population worldwide. It can present many challenges and can therefore be difficult to treat successfully by mental health professionals.

Aim: The aim of this systematic review was to detect whether repetitive Transcranial Magnetic Stimulation (rTMS) is an effective intervention for the management of BPD to the point where there would be a reduction of the BPD symptoms and challenging behaviour.

Methods: A literature search was conducted systematically using the following databases: PROSPERO, PUBMED, GOOGLE SCHOLAR, WEB OF SCIENCE, COCHRANE LIBRARY, SCOPUS, EMBASE and CLINICALTRIALS.GOV. Included studies were primary research studies of adult patients with a diagnosis of BPD who received rTMS treatment.

Results: Nine studies were identified which ranged from a case report to a randomised controlled trial (RCT). While rTMS improved certain symptoms of BPD patients, such as affective instability, impulsivity and outbursts of anger; overall, some results lacked statistical significance and, due to the lack of robust evidence, it is uncertain if rTMS is an effective intervention for BPD.

Conclusions: rTMS treatment showed some promising results in reducing the severity of symptoms for a number of patients. Studies varied with regard to the location of the target stimulation site, including different prefrontal brain regions and the cerebellum, as well as other rTMS protocol characteristics. These methodological differences in the application of the intervention and their impact on BPD symptomatology need to be explored more systematically in future research. Higher quality studies with larger sample sizes are needed in order to assess further the effectiveness of rTMS interventions on BPD symptoms.

Keywords: Borderline personality disorder, mental health, repetitive transcranial magnetic stimulation, intervention, randomised controlled trial, BPD symptoms and challenges.

Graphical Abstract
[1]
Kelleher I, Cannon M. Whither the psychosis-neurosis borderline. Schizophr Bull 2014; 40(2): 266-8.
[http://dx.doi.org/10.1093/schbul/sbt230] [PMID: 24436054]
[2]
Douzenis A, Tsopelas C, Tzeferakos G. Medical comorbidity of cluster B personality disorders. Curr Opin Psychiatry 2012; 25(5): 398-404.
[http://dx.doi.org/10.1097/YCO.0b013e3283558491] [PMID: 22744403]
[3]
Selby EA. Chronic sleep disturbances and borderline personality disorder symptoms. J Consult Clin Psychol 2013; 81(5): 941-7.
[http://dx.doi.org/10.1037/a0033201] [PMID: 23731205]
[4]
Kendall T, Pilling S, Tyrer P, et al. Borderline and antisocial personality disorders: summary of NICE guidance. BMJ 2009; 338(jan28 2): b93.
[5]
Zhu XM, Zhou JS, Chen C, et al. Prevalence of borderline personality disorder and its risk factors in female prison inmates in China. Psychiatry Res 2017; 250: 200-3.
[http://dx.doi.org/10.1016/j.psychres.2017.01.065] [PMID: 28167433]
[6]
Krause-Utz A, Winter D, Schriner F, et al. Reduced amygdala reactivity and impaired working memory during dissociation in borderline personality disorder. Eur Arch Psychiatry Clin Neurosci 2018; 268(4): 401-15.
[http://dx.doi.org/10.1007/s00406-017-0806-x] [PMID: 28526931]
[7]
Krause-Utz A, Winter D, Niedtfeld I, Schmahl C. The latest neuroimaging findings in borderline personality disorder. Curr Psychiatry Rep 2014; 16(3): 438.
[http://dx.doi.org/10.1007/s11920-014-0438-z] [PMID: 24492919]
[8]
Kraus A, Valerius G, Seifritz E, et al. Script-driven imagery of self-injurious behavior in patients with borderline personality disorder: a pilot FMRI study. Acta Psychiatr Scand 2010; 121(1): 41-51.
[http://dx.doi.org/10.1111/j.1600-0447.2009.01417.x] [PMID: 19522883]
[9]
Soloff PH, Abraham K, Burgess A, Ramaseshan K, Chowdury A, Diwadkar VA. Impulsivity and aggression mediate regional brain responses in Borderline Personality Disorder: An fMRI study. Psychiatry Res Neuroimaging 2017; 260: 76-85.
[http://dx.doi.org/10.1016/j.pscychresns.2016.12.009] [PMID: 28039797]
[10]
Kumar N, Jha S. Repetitive Transcranial Magnetic Stimulation (RTMS) in organic personality and behavioral disorder, secondary to suicide attempt by hanging. Clin Neurophysiol 2013; 124(10): e165-6.
[http://dx.doi.org/10.1016/j.clinph.2013.04.290]
[11]
Trojak B, Meille V, Jonval L, et al. Interest of targeting either cortical area Brodmann 9 or 46 in rTMS treatment for depression: A preliminary randomized study. Clin Neurophysiol 2014; 125(12): 2384-9.
[http://dx.doi.org/10.1016/j.clinph.2014.04.001] [PMID: 24794512]
[12]
George MS, Raman R, Benedek DM, et al. A two-site pilot randomized 3 day trial of high dose left prefrontal repetitive transcranial magnetic stimulation (rTMS) for suicidal inpatients. Brain Stimul 2014; 7(3): 421-31.
[http://dx.doi.org/10.1016/j.brs.2014.03.006] [PMID: 24731434]
[13]
Cheng P, Zhou Y, Xu LZ, et al. Clinical application of repetitive transcranial magnetic stimulation for post-traumatic stress disorder: A literature review. World J Clin Cases 2021; 9(29): 8658-65.
[http://dx.doi.org/10.12998/wjcc.v9.i29.8658] [PMID: 34734044]
[14]
Concerto C, Lanza G, Fisicaro F, et al. Repetitive transcranial magnetic stimulation for post-traumatic stress disorder: Lights and shadows. World J Clin Cases 2022; 10(17): 5929-33.
[http://dx.doi.org/10.12998/wjcc.v10.i17.5929] [PMID: 35979128]
[15]
Bloch Y, Harel EV, Aviram S, Govezensky J, Ratzoni G, Levkovitz Y. Positive effects of repetitive transcranial magnetic stimulation on attention in ADHD Subjects: A randomized controlled pilot study. World J Biol Psychiatry 2010; 11(5): 755-8.
[http://dx.doi.org/10.3109/15622975.2010.484466] [PMID: 20521875]
[16]
Garg S, Sinha VK, Tikka SK, Mishra P, Goyal N. The efficacy of cerebellar vermal deep high frequency (theta range) repetitive transcranial magnetic stimulation (rTMS) in schizophrenia: A randomized rater blind-sham controlled study. Psychiatry Res 2016; 243: 413-20.
[http://dx.doi.org/10.1016/j.psychres.2016.07.023] [PMID: 27450744]
[17]
Connolly KR, Helmer A, Cristancho MA, Cristancho P, O’Reardon JP. Effectiveness of transcranial magnetic stimulation in clinical practice post-FDA approval in the United States: results observed with the first 100 consecutive cases of depression at an academic medical center. J Clin Psychiatry 2012; 73(4): e567-73.
[http://dx.doi.org/10.4088/JCP.11m07413] [PMID: 22579164]
[18]
Di Lazzaro V, Bella R, Benussi A, et al. Diagnostic contribution and therapeutic perspectives of transcranial magnetic stimulation in dementia. Clin Neurophysiol 2021; 132(10): 2568-607.
[http://dx.doi.org/10.1016/j.clinph.2021.05.035] [PMID: 34482205]
[19]
Soloff P, Nutche J, Goradia D, Diwadkar V. Structural brain abnormalities in borderline personality disorder: A voxel-based morphometry study. Psychiatry Res Neuroimaging 2008; 164(3): 223-36.
[http://dx.doi.org/10.1016/j.pscychresns.2008.02.003] [PMID: 19019636]
[20]
Soloff P, Meltzer C, Becker C, Greer P, Kelly T, Constantine D. Impulsivity and prefrontal hypometabolism in borderline personality disorder. Psychiatry Res Neuroimaging 2003; 123(3)
[http://dx.doi.org/10.1016/S0925-4927(03)00064-7]
[21]
Downar J, Blumberger DM, Daskalakis ZJ. Repetitive transcranial magnetic stimulation: an emerging treatment for medication-resistant depression. CMAJ 2016; 188(16): 1175-7.
[http://dx.doi.org/10.1503/cmaj.151316] [PMID: 27551033]
[22]
Choi-kain L, Glasserman E, Finch E. Borderline personality disorder: treatment resistance reconsidered 2017. Available from: https://www.psychiatrictimes.com/special-reports/borderline-personality-disorder-treatment-resistance-reconsidered(Accessed on: 2019 Sept 19).
[23]
Konstantinou GN, Trevizol AP, Downar J, et al. Repetitive transcranial magnetic stimulation in patients with borderline personality disorder: A systematic review. Psychiatry Res 2021; 304: 114145.
[http://dx.doi.org/10.1016/j.psychres.2021.114145] [PMID: 34358761]
[24]
De Vidovich GZ, Muffatti R, Monaco J, et al. Repetitive TMS on left cerebellum affects impulsivity in borderline personality disorder: A pilot study. Front Hum Neurosci 2016; 10: 582.
[http://dx.doi.org/10.3389/fnhum.2016.00582]
[25]
Saaiq M, Ashraf B. Modifying “Pico” question into “Picos” model for more robust and reproducible presentation of the methodology employed in a scientific study. World J Plast Surg 2017; 6(3): 390-2.
[PMID: 29218294]
[26]
Noohi S, Amirsalari S. History, Studies and Specific Uses of Repetitive Transcranial Magnetic Stimulation (rTMS) in Treating Epilepsy. Iran J Child Neurol 2016; 10(1): 1-8.
[PMID: 27057180]
[28]
Vahia V. Diagnostic and statistical manual of mental disorders 5: A quick glance. Indian J Psychiatry 2013; 55(3): 220-3.
[http://dx.doi.org/10.4103/0019-5545.117131] [PMID: 24082241]
[29]
Semple D, Smyth R. Oxford handbook of psychiatry. (3rd ed.), UK: Oxford University Press 2013.
[http://dx.doi.org/10.1093/med/9780199693887.001.0001]
[30]
Higgins JPT, Thomas J, Chandler J, et al. Cochrane handbook for systematic reviews of interventions. Lincoln: Cochrane Training 2022. Available from: http://www.training.cochrane.org/handbook
[31]
Sterne JAC. Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898.
[http://dx.doi.org/10.1136/bmj.l4898] [PMID: 31462531]
[32]
Sterne JAC, Hernán MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919.
[http://dx.doi.org/10.1136/bmj.i4919] [PMID: 27733354]
[33]
Wells G, Shea BJ, O’Connell DO, et al. The Newcastle– Ottawa Scale (NOS) for assessing the quality of non-randomized studies in meta-analysis. Available from:https://web.archive.org/web/20210716121605id_/ http://www3.med.unipmn.it/dispense_ebm/2009-2010/Corso%20Perfezionamento%20EBM_Faggiano/NOS_oxford.pdf
[34]
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009; 6(7): e1000097.
[http://dx.doi.org/10.1371/journal.pmed.1000097] [PMID: 19621072]
[35]
Reyes-López J, Ricardo-Garcell J, Armas-Castañeda G, et al. Clinical improvement in patients with borderline personality disorder after treatment with repetitive transcranial magnetic stimulation: preliminary results. Rev Bras Psiquiatr 2017; 40(1): 97-104.
[http://dx.doi.org/10.1590/1516-4446-2016-2112] [PMID: 28614492]
[36]
Calderón-Moctezuma AR, Reyes-López JV, Rodríguez-Valdés R, et al. Improvement in borderline personality disorder symptomatology after repetitive transcranial magnetic stimulation of the dorsomedial prefrontal cortex: Preliminary results. Br J Psychiatry 2021; 43(1): 65-9.
[http://dx.doi.org/10.1590/1516-4446-2019-0591] [PMID: 32876128]
[37]
Cailhol L, Roussignol B, Klein R, et al. Borderline personality disorder and rTMS: A pilot trial. Psychiatry Res 2014; 216(1): 155-7.
[http://dx.doi.org/10.1016/j.psychres.2014.01.030] [PMID: 24503285]
[38]
Hasani N, Oghabian MA, Arbabi M, Hafizi S, Gholami S. Evaluation of fMRI analysis to study treatment effect of TMS in borderline personality disorder. Long M, Ed World Congress on Medical Physics and Biomedical Engineering. Beijing, China. Berlin, Heidelberg: Springer 2012; vol 39.
[39]
věrák T, Linhartová P, Kuhn M, et al. Transcranial magnetic stimulation in borderline personality disorder- Case series. Ces Slov Neurol Neurochir 2019; 82/115(1): 48-52.
[40]
Feffer K, Peters SK, Bhui K, Downar J, Giacobbe P. Successful dorsomedial prefrontal rTMS for major depression in borderline personality disorder: Three cases. Brain Stimul 2017; 10(3): 716-7.
[http://dx.doi.org/10.1016/j.brs.2017.01.583] [PMID: 28196679]
[41]
Arbabi M, Hafizi S, Ansari S, Oghabian MA, Hasani N. High frequency TMS for the management of borderline personality disorder: A case report. Asian J Psychiatr 2013; 6(6): 614-7.
[http://dx.doi.org/10.1016/j.ajp.2013.05.006] [PMID: 24309885]
[42]
Gundogmus I, Ornek BY. Altınyay N. Effectiveness of repetitive transcranial magnetic stimulation (rTMS) on borderline personality disorder symptoms: A case report. Psychiatr Behav Sci 2019; 9(1-2): 53-6.
[http://dx.doi.org/10.5455/PBS.20180702035133]
[43]
Cantone M, Lanza G, Ranieri F, Opie GM, Terranova C. Editorial: Non-invasive brain stimulation in the study and modulation of metaplasticity in neurological disorders. Front Neurol 2021; 721906.
[http://dx.doi.org/10.3389/fneur.2021.721906]
[44]
Shaikh U, Qamar I, Jafry F, et al. Patients with borderline personality disorder in emergency departments. Front Psychiatry 2017; 8: 136.
[http://dx.doi.org/10.3389/fpsyt.2017.00136] [PMID: 28824467]
[45]
Terzi L, Martino F, Berardi D, Bortolotti B, Sasdelli A, Menchetti M. Aggressive behavior and self-harm in Borderline Personality Disorder: The role of impulsivity and emotion dysregulation in a sample of outpatients. Psychiatry Res 2017; 249: 321-6.
[http://dx.doi.org/10.1016/j.psychres.2017.01.011] [PMID: 28152466]
[46]
NCCMH Borderline personality disorder: treatment and management NICE Clinical Guidelines, 2009; No 78 National Collaborating Centre for Mental Health (UK). Leicester, UK: British Psychological Society 2009.
[47]
Kay ML, Poggenpoel M, Myburgh CP, Downing C. Experiences of family members who have a relative diagnosed with borderline personality disorder. Curationis 2018; 41(1): e1-9.
[http://dx.doi.org/10.4102/curationis.v41i1.1892] [PMID: 30326706]
[48]
Chu S. What do we know about special observations in the care of psychiatric inpatients?. 2014. Available from: https://www.merseycare.nhs.uk/media/4267/simonfinallitrev.pdf
[49]
Linehan M, Cochran B, Mar C, Levensky E, Comtois K. Therapeutic burnout among borderline personality disordered clients and their therapists: Development and evaluation of two adaptations of the maslach burnout inventory. Cognit Behav Pract 2000; 7(3): 329-37.
[50]
Johnson J, Hall LH, Berzins K, Baker J, Melling K, Thompson C. Mental healthcare staff well-being and burnout: A narrative review of trends, causes, implications, and recommendations for future interventions. Int J Ment Health Nurs 2018; 27(1): 20-32.
[http://dx.doi.org/10.1111/inm.12416] [PMID: 29243348]
[51]
Asselt T, Dirksen D, Arntz C, Severens A. The cost of borderline personality disorder: societal cost of illness in BPD-patients. Eur Psychiatry 2007; 22: 354-61.
[http://dx.doi.org/10.1016/j.eurpsy.2007.04.001]
[52]
Barnicot K, Insua-Summerhayes B, Plummer E, Hart A, Barker C, Priebe S. Staff and patient experiences of decision-making about continuous observation in psychiatric hospitals. Soc Psychiatry Psychiatr Epidemiol 2017; 52(4): 473-83.
[http://dx.doi.org/10.1007/s00127-017-1338-4] [PMID: 28161766]
[53]
Conn C, Warden R, Stuewig J, et al. Borderline personality disorder among jail inmates: how common and how distinct? Correct Compend 2010; 35(4): 6-13.
[PMID: 27065512]
[54]
Goyal S, Singh P, Gargi P, Goyal S, Garg A. Psychiatric morbidity in prisoners. Indian J Psychiatry 2011; 53(3): 253-7.
[http://dx.doi.org/10.4103/0019-5545.86819] [PMID: 22135446]
[55]
NIMHE. Personality Disorder: No longer a diagnosis of exclusion. 2003.
[56]
Razza LB, Moffa AH, Moreno ML, et al. A systematic review and meta-analysis on placebo response to repetitive transcranial magnetic stimulation for depression trials. Prog Neuropsychopharmacol Biol Psychiatry 2018; 81: 105-13.
[http://dx.doi.org/10.1016/j.pnpbp.2017.10.016] [PMID: 29111404]
[57]
Biskin R, Paris J. Comorbidities in borderline personality disorder 2013. Available from: https://www. psychiatrictimes.com/borderline-personality/comorbi-dities-borderline-personality-disorder (Accessed on: 2019 Aug 25).
[58]
Beatson JA, Rao S. Depression and borderline personality disorder. Med J Aust 2013; 199(S6) (Suppl.): S24-7.
[http://dx.doi.org/10.5694/mja12.10474] [PMID: 25370280]
[59]
Porto R. The Placebo effect: Its importance in treatment. Sexologies 2011; 20(1): 15-9.
[http://dx.doi.org/10.1016/j.sexol.2011.01.008]
[60]
Lubit R. Borderline personality disorder treatment and management 2018. Available from: https://emedicine.medscape.com/article/913575-treatment#d10 (Accessed on: 2019 June 20).
[61]
Bankhead C, Aronson JK, Nunan D. 2017. Available from: https://catalogofbias.org/biases/attrition-bias/ (Accessed on: 2019 June 20)
[62]
Banerjee A, Pluddemann A, O’Sullivan J, Nunan D. Perfomance bias 2019. Available from: https://catalogofbias.org/biases/performance-bias/ (Accessed on: 2019 June 20).
[63]
Page LA, Henderson M. Appraising the evidence: what is measurement bias? Evid Based Ment Health 2008; 11(2): 36-7.
[http://dx.doi.org/10.1136/ebmh.11.2.36] [PMID: 18441127]
[64]
Skodol AE, Bender DS. Why are women diagnosed borderline more than men? Psychiatr Q 2003; 74(4): 349-60.
[http://dx.doi.org/10.1023/A:1026087410516] [PMID: 14686459]
[65]
Khasho DA, van Alphen SPJ, Heijnen-Kohl SMJ, Ouwens MA, Arntz A, Videler AC. The effectiveness of individual schema therapy in older adults with borderline personality disorder: Protocol of a multiple-baseline study. Contemp Clin Trials Commun 2019; 14: 100330.
[http://dx.doi.org/10.1016/j.conctc.2019.100330] [PMID: 30775612]
[66]
Mahtani K, Spencer EA, Brassey J. Observer Bias: Catalogue of Bias 2017. Available from: https://catalogofbias.org/biases/observer-bias/ (Accessed on: 2019 july 7).
[67]
Lieb K, Völlm B, Rücker G, Timmer A, Stoffers JM. Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. Br J Psychiatry 2010; 196(1): 4-12.
[http://dx.doi.org/10.1192/bjp.bp.108.062984] [PMID: 20044651]
[68]
Belli H, Ural C, Akbudak M. Borderline personality disorder: bipolarity, mood stabilizers and atypical antipsychotics in treatment. J Clin Med Res 2012; 4(5): 301-8.
[http://dx.doi.org/10.4021/jocmr1042w] [PMID: 23024731]
[69]
Greenshaw AJ. Neurotransmitter interactions in psychotropic drug action: beyond dopamine and serotonin. J Psychiatry Neurosci 2003; 28(4): 247-50.
[PMID: 12921219]
[70]
Bateman AW, Fonagy P. Effectiveness of psychotherapeutic treatment of personality disorder. Br J Psychiatry 2000; 177(2): 138-43.
[http://dx.doi.org/10.1192/bjp.177.2.138] [PMID: 11026953]
[71]
Cambanis EVA. Treating borderline personality disorder as a trainee psychologist: Issues of resistance, inexperience and countertransference. J Child Adolesc Ment Health 2012; 24(1): 99-109.
[http://dx.doi.org/10.2989/17280583.2011.639075] [PMID: 25865841]
[72]
Bellino S, Rinaldi C, Bogetto F. Adaptation of interpersonal psychotherapy to borderline personality disorder: a comparison of combined therapy and single pharmacotherapy. Can J Psychiatry 2010; 55(2): 74-81.
[http://dx.doi.org/10.1177/070674371005500203] [PMID: 20181302]
[73]
Vohra A. Treatment of severe borderline personality disorder with clozapine. Indian J Psychiatry 2010; 52(3): 267-9.
[http://dx.doi.org/10.4103/0019-5545.70989] [PMID: 21180415]
[74]
Gerlach J. Clozapine side effects, Nordic. J Psychiatr 1998; 51sup40: 65-8.
[http://dx.doi.org/10.1080/08039488.1998.11884455]
[75]
Kar N, Barreto S, Chandavarkar R. Clozapine monitoring in clinical practice: beyond the mandatory requirement. Clin Psychopharmacol Neurosci 2016; 14(4): 323-9.
[http://dx.doi.org/10.9758/cpn.2016.14.4.323] [PMID: 27776383]
[76]
McLean MM, Sherwin H, Madabhushi V, Tilney PVRA. 17-year-old female patient with a lithium overdose. Air Med J 2015; 34(4): 162-5.
[http://dx.doi.org/10.1016/j.amj.2015.04.010] [PMID: 26206537]
[77]
Leong C, Alessi-Severini S, Sareen J, Enns MW, Bolton J. Community pharmacists’ perspectives on dispensing medications with the potential for misuse, diversion, and intentional overdose: Results of a province-wide survey of community pharmacists in Canada. Subst Use Misuse 2016; 51(13): 1724-30.
[http://dx.doi.org/10.1080/10826084.2016.1197261] [PMID: 27487323]
[78]
Humaira A, Downar J, Blumberger D, et al. Repetitive transcranial magnetic stimulation (rTMS) side effect characterization for treatment resistant depression: Non-inferiority rTMS trial. Brain Stimul 2017; 10(2): 521.
[http://dx.doi.org/10.1016/j.brs.2017.01.522]
[79]
Smart TMS. 2015. Available from: https://www.smarttms.co.uk/borderline-personality-disorder (Accessed on: 2019 july 14).
[80]
Panihhidina I. Repetitive transcranial magnetic stimulation for the treatment of resistant depression.results from the treatment cohort attending the london psychiatry centre. 2019. Available from: https://www. psychiatrycentre.co.uk/wp-content/uploads/2019/02/Repetitive-Transcranial-Magnetic-Stimulation-for-the-treatment-of-resistant-depression.-Results-from-the-treatment-cohort-attending-The-London-Psychiatry- Centre.pdf(Accessed on: 2019 june 15).

Rights & Permissions Print Cite
© 2024 Bentham Science Publishers | Privacy Policy