Emotion-focused vs. cognitive interventions of schema therapy for borderline personality disorder: effects on neural emotion regulation networks - study protocol

Abstract

Background: While the effects of psychotherapy methods are being intensively researched, little is known about the clinical and neurobiological effects of specific psychotherapeutic interventions. This study examines the effects of experiential emotion-focused and cognitive interventions in schema therapy on emotion regulation in borderline personality disorder.

Methods: In a randomized, single-blinded, parallel group design, clinical effects and effects on resting-state functional connectivity in neural emotion regulation networks and neurotransmitter metabolism (Glx/GABA) in key regions of these networks are compared. The 9-week treatment protocol includes emotion-focused interventions such as chair dialogues, imagery rescripting, or mode role-playing in the test condition; these interventions are omitted in the active control condition (dismantling design). Resting-state functional MR imaging (rsfMRI) and MEGA-sLASER 1 H MR spectroscopy in the pregenual cingulate cortex (pgACC), anteromedial cingulate cortex (aMCC), and dorsolateral prefrontal cortex (DLPFC) are performed before and after the therapy interval and 6 months after the end of therapy and compared with the neurobiological parameters of healthy control subjects. The clinical effects are recorded using a comprehensive test battery and specified using the Reliable Change Index (RCI). Clinical and biological data are examined using mixed model analysis both longitudinally and in terms of their interactions.

Discussion: The aim is to show that different psychotherapeutic interventions have different effects on deficits in emotion regulation associated with specific effects on neural emotion regulation networks. This would contribute to a better understanding of the neurobiological effects and mechanisms underlying psychotherapeutic core interventions and to their more targeted use in BPD and other related disorders in the future.

Trial registration: ClinicalTrials.gov Identifier: NCT06367907, Retrospectively registered, April 2024.

Keywords: Behavioral therapy; Borderline personality disorder; Functional brain connectivity; GABA; Glutamate; Proton MR spectroscopy; Resting-state functional MR imaging; Schema therapy.

Fig. 1

Involved networks and target regions: Illustration of brain regions in the default mode network (DMN) [24, 25], the salience network (SN) and the executive control network (ECN) [–28]. DMN (marked in green):ventromedial prefrontal cortex (vmPFC), dorsomedial prefrontal cortex (dmPFC), perigenual anterior cingulate cortex (pgACC), posterior cingulate cortex (PCC), hippocampus (Hipp), inferior parietal lobule (IPL), lateral temporal cortex (LTC) SN (marked in yellow): dorsolateral anterior insular cortex (AI), dorsolateral anterior cingulate cortex (aMCC, previous dACC), ventral striatum (VS), Amygdala (AMY) ECN (marked in blue): dorsolateral and ventrolateral prefrontal cortex (dlPFC, vlPFC), superior parietal lobule (SPL)

Fig. 2

Study design: T0/T1 First therapeutic phase is divided into an emotion-focused (ST-EF) and an active control (ST-AC) condition in terms of emotion-focused interventions of ST. It enables the assessment of differential effects of the experiential therapeutic techniques of ST: (i) as compared to the cognitive behavioral techniques serving as control condition (T0/T1), (ii) as compared to the influence of time (T0 vs. T1 in healthy controls), (iii) and as compared to medium-term treatment effects. Marked in grey: Target group sizes as derived from the power calculation, and including possible dropouts in each group