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I would like to take this opportunity to provide the International Society for Traumatic Stress Studies members an overview of recent developments in the fields of emotion regulation and neurofeedback, which are closely related to the interaction between neuroscientific and psychotherapy research. I am convinced that integration of both research methodologies can significantly help to improve the basic understanding of mechanisms behind disorders related to traumatic stress. I would also like to share some insights on how a better understanding of the neural mechanisms behind emotion dysregulation can help to develop new treatment options for these disorders.

Emotion dysregulation is a core feature of disorders related to traumatic stress, such as complex Posttraumatic Stress Disorder (cPTSD) or Borderline Personality Disorder (BPD), and a main target of many psychotherapeutic approaches for these disorders. In BPD and cPTSD, neuroimaging studies investigating alterations after treatment have found normalization of limbic hyper-reactivity, particularly in the amygdala. The amygdala is a central nucleus for the processing of emotions and was found to be hyper-reactive to emotional stimuli in both PTSD and BPD. After successful therapy, patients exhibited changes in brain activity, pointing to reduced hypersensitivity of limbic brain regions and increased prefrontal brain activity during emotional challenge. A recent study observed reduced neural activity in eight patients with BPD in brain areas supporting emotion processing and theory of mind after brief psychiatric treatment of 10 sessions (Kramer et al. 2018).

Three studies were conducted by our group in Germany in a project investigating different emotion regulation strategies (reappraisal, distraction and pain) before and after a 12-week residential Dialectical and Behavioural Therapy (DBT; Linehan, 1993) treatment (Niedtfeld et al., 2017; Schmitt et al., 2016; Winter et al., 2016), as compared to treatment as usual and healthy control participants. Most patients also fulfilled diagnostic criteria for cPTSD. When engaging in reappraisal of negative pictures, patients showed decreased anterior insula and dorsal anterior cingulate cortex (ACC) activity during and after DBT. Therapy responders also showed reduced activation in amygdala, ACC, orbitofrontal and dorsolateral prefrontal cortex (DLPFC), together with increased limbic-prefrontal coupling (Schmitt et al., 2016).

In the second study, DBT treatment responders also showed reduced ACC activity when viewing negative (as compared to neutral) pictures. During cognitive distraction from negative pictures, decreased activity in the right inferior parietal lobe was found in BPD patients after DBT (Winter et al., 2016). The third study examined the effect of pain on emotional reactions and found that pain-mediated affect regulation (i.e., amygdala deactivation in response to painful stimulation, a mechanism assumed to underlie non-suicidal self-injury) was reduced after DBT treatment (Niedtfeld et al., 2017). Amygdala deactivation in response to painful stimuli could be demonstrated not only in patients with BPD, but also in veterans with PTSD.

Taken together, there is strong evidence for limbic hyper-reactivity in BPD and cPTSD, leading to intense and long-lasting emotional reactions. Additionally, down-regulation of emotional arousal appears to be deficient, as demonstrated by decreased recruitment of prefrontal regulation networks. These two aspects might result in affective instability in these patients. However, it is important to note that most of these effects might be not specific to particular diagnostic groups. A study in healthy subjects with childhood maltreatment demonstrated functional alterations that were strikingly similar to the findings described here for BPD. It is possible that adverse childhood experiences lead to alterations in limbic brain regions, which in turn increase the risk for the development of psychiatric disorders in general.

Another example for an integrated neuroscientific-psychotherapeutic as well as mechanism-based approach is real-time fMRI neurofeedback (rtfmri-NF). Rtfmri-NF has recently become a focus of clinical psychiatry and psychotherapy research, with pioneering studies providing initial evidence that it might play a promising role in future therapies for chronic pain and mental disorders such as depression, schizophrenia and phobias. Several studies conducted in healthy participants have demonstrated improvement in control over key areas of emotional responding, such as the amygdala or the insula. This literature supports the feasibility of using neurofeedback to target brain regions of the affective system, such as the amygdala, as an alternative or at least an add-on to psychotherapy for mental disorders that are associated with emotion dysregulation.

We investigated whether participants would be able to down-regulate their amygdala response to aversive pictures when they were provided with continuous feedback from this region. The first study was conducted in healthy persons (Paret, Kluetsch, Ruf, Demirakca, Hoesterey, et al., 2014). Thirty-two female participants completed one session of training that comprised four runs, with each run presenting aversive pictures under three different conditions. In the REGULATE condition, participants were provided with continuous visual feedback on brain activation via a thermometer display and were instructed to use this feedback to try to consciously down-regulate the thermometer. Half of the participants received feedback on activation in the amygdala, while the other half received it from a control region located in the basal ganglia. In the VIEW condition, they were instructed to respond naturally to the aversive pictures; i.e., to not make any attempt to regulate the thermometer. In the fourth run, they were given the same instructions about down-regulation that they had been given in the REGULATE condition, but this time they did not receive feedback on brain activation, in order to assess the transfer of the regulation training. Rtfmri-NF was associated with successful down-regulation of the amygdala response in both groups.

In a second study  (Paret, Kluetsch, et al., 2016), we applied the same protocol to eight BPD patients to investigate if down-regulation of amygdala activation could be achieved in this population as well. Participants underwent four training sessions over two weeks. We found a reduced amygdala response in the REGULATE condition as contrasted with the VIEW condition, with reduction already seen in the first session. BPD patients also demonstrated an increase of amygdala-prefrontal connectivity over the course of training, a pattern which was also observed in healthy subjects during one session of rtfmri-NF. Very similar findings of successful amygdala down-regulation could also be demonstrated in patients with PTSD following different types of trauma (Nicholson et al. 2017).

In a recently completed study (Zähringer et al. 2019), we were interested in which aspects of emotion dysregulation would be amenable to change with NF. Twenty-five female BPD patients participated in three rtfMRI-NF sessions and were tested again six weeks later. Patients were on constant medication or outpatient treatment throughout the study period. Emotion regulation was assessed on physiological, behavioral and self-report levels. Results again show significant down-regulation of amygdala activation. After training, patients indicated less aversive arousal and negative emotions, as well as lower hour-to-hour variability in these measures. BPD symptoms decreased in results from the Zanarini-Scale for BPD. In the psychophysiology lab, patients improved emotion regulation skills after training, indicated by decreased startle response to negative pictures. Taken together, this one-arm clinical study revealed significant improvement in emotion regulation and reductions in affective instability in daily life after fMRI-NF in BPD. The treatment affected emotion processing on several systems levels, including psychophysiology, behavior and subjective experience. To control for psychosocial effects, future studies need to compare the treatment with a control group.

These examples depicted here may help to illustrate how state-of-the art neuroscientific methodology and psychotherapy work hand in hand to understand mechanisms of change in BPD and cPTSD treatment as well as develop innovative yet experimental therapy approaches. This integrated approach not only broadens our view on these complex disorders, but also gives hope to a better understanding and treatment of disturbed emotion regulation in and beyond BPD. For the clinician, it is important to note how closely symptoms of emotion dysregulation can be monitored in the brain and that the altered patterns of brain function can be modified by psychotherapy or neurofeedback. We are currently developing easier and cheaper methods of amygdala-neurofeedback, which can then be used in everyday life and be combined with psychotherapy in trauma-related disorders. Meanwhile and in addition to these new techniques, teaching of behavioral skills, for example in the context of DBT, is an effective way to improve emotion regulation and reduce behavioral problems in patients with complex trauma-related disorders. 

About the Author

Christian Schmahl, MD, is professor of experimental psychopathology and medical director of the Department of Psychosomatic Medicine at the Central Institute of Mental Health at Heidelberg University, in Germany. He is a current member of the ISTSS Board of Directors and an associate editor of the Journal of Traumatic Stress.


Kramer, U., Kolly, S., Maillard, P., Pascual-Leone, A., Samson, A. C., Schmitt, R., . . . de Roten, Y. (2018). Change in Emotional and Theory of Mind Processing in Borderline Personality Disorder: A Pilot Study. The Journal of Nervous and Mental Disease, 206(12), 935-943.

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Nicholson, A., Rabellino, D., Densmore, M., Frewen, P., Paret, C., Kluetsch, R., Schmahl, C., Theberge, J., Neufeld, R., McKinnon, M., Reiss, J., Jetly, R., Lanius, R. (2017). The neurobiology of emotion regulation in posttraumatic stress disorder: Amygdala downregulation via real-time fMRI neurofeedback. Human Brain Mapping, 38, 541-560.

Niedtfeld, I., Schmitt, R., Winter, D., Bohus, M., Schmahl, C., & Herpertz, S. C. (2017). Pain-mediated affect regulation is reduced after dialectical behavior therapy in borderline personality disorder: A longitudinal fMRI study. Social Cognitive and Affective Neuroscience, 12, 739-747.

Paret, C., Kluetsch, R., Ruf, M., Demirakca, T., Hoesterey, S., Ende, G., & Schmahl, C. (2014). Down-regulation of amygdala activation with real-time fMRI neurofeedback in a healthy female sample. Frontiers in Behavioral Neuroscience, 8, 299. doi:10.3389/fnbeh.2014.00299

Paret, C., Kluetsch, R., Zaehringer, J., Ruf, M., Demirakca, T., Bohus, M., . . . Schmahl, C. (2016). Alterations of amygdala-prefrontal connectivity with real-time fMRI neurofeedback in BPD patients. Social Cognitive and Affective Neuroscience, 11, 952-960. doi:10.1093/scan/nsw016

Schmitt, R., Winter, D., Niedtfeld, I., Schmahl, C., & Herpertz, S. C. (2016). Effects of psychotherapy on neuronal correlates of reappraisal in female patients with borderline personality disorder. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 1, 548-557. doi:10.1007/s00406-016-0689-2

Winter, D., Niedtfeld, I., Schmitt, R., Bohus, M., Schmahl, C., & Herpertz, S. C. (2016). Neural correlates of distraction in borderline personality disorder before and after dialectical behavior therapy. European Archives of Psychiatry and Clinical Neuroscience, 267, 51-62. doi:10.1007/s00406-016-0689-2

Zaehringer, J.K., Ende, G., Santangelo, P., Kleindienst, N., Ruf, M., Bertsch, K., Bohus, M., Schmahl, C., & Paret, C. (2019). Improved emotion regulation after neurofeedback: A single-arm trial in patients with borderline personality disorder. Neuroimage Clinical 24, 102032.