اختلال شخصیت مرزی و rTMS : یک مطالعه آزمایشی

Abstract A randomized, controlled study was carried out to assess the effect of a series of 10 sessions of high-frequency rTMS to the right DLPFC in 10 Borderline Personality Disorder patients. Patients in the rTMS group showed improvements in anger, affective instability (Borderline Personality Disorder Severity Index) and planning (Tower Of London). Two smoking cessations were observed.

Introduction The neuromodulatory effects of Transcranial Magnetic Stimulation (TMS) on the cerebral cortex suggest that rTMS may be a potential treatment for some Borderline Personality Disorder (BPD) symptoms. Some recent functional neuroimaging research supports the hypothesis of a dysfunctional frontolimbic network in BPD (Leichsenring et al., 2011, Schmahl and Bremner, 2006 and Stein, 2009). PET ([18F]fluoro-d-glucose) studies show hypometabolism in the prefrontal cortex (De La Fuente et al., 1997 and Salavert et al., 2011). The involvement of the prefrontal cortex in BPD is also supported by neuropsychological findings (Ruocco et al., 2010 and Ruocco, 2005). These studies suggest the presence of a cortical dysfunction that might be normalized by rTMS. Other studies indicate that both electric and magnetic stimulation of the right Dorsolateral Prefrontal Cortex (rDLPFC) affect decision-making (Fecteau et al., 2007, Knoch et al., 2006a, Knoch et al., 2006b and van ׳t Wout et al., 2005). Deficits in decision-making were correlated with BPD symptom severity (Schuermann et al., 2011 and Svaldi et al., 2012). These arguments suggest that the rDLPFC may be a potential target for cortical stimulation of BPD patients. Our objective was to assess the effect of a series of 10 daily sessions of high-frequency rTMS applied to the rDLPFC on the severity of BPD and the results of neuropsychological tasks in BPD patients.

Results Enrollment began in January 2010 and ended in January 2011. Analyses were performed on nine subjects (five rTMS and four sham rTMS). The two groups were comparable in terms of age and severity of BPD. The groups differed in terms of sex (one male in the rTMS group). For the main clinical outcome measure (the BPDSI), the response rate (at least 30% reduction on the BPDSI) is two of five for the rTMS group and one of four for the sham rTMS group. The nine items of the BPDSI were compared at intake and 3 months. At 3 months we found differences for affective instability (Mean: 0.07 (S.D.=0.13) vs. 1.22 (S.D.=0.82), t=−0.961, d.f.=7, p=0.017) and anger (Mean: 0.6 (S.D.=0.52) vs. 2.1 (S.D.=1.14), t=−2.672, d.f.=7, p=0.032). All other outcomes are provided in Table 1. The performance in the TOL improved significantly in the rTMS group (baseline: 4.17 (S.D.=0.08) and 3 months: 4.11 (S.D.=0.074); t=3.127, d.f.=4, p=0.035), whereas this was not the case in the sham-rTMS group (baseline: 4.15 (S.D.=0.073) and 3 months: 4.10 (S.D.=0.066); t=−0.694, d.f.=3, p=0.54). Data related to the TOL are presented in Table 2. Two patients reported having stopped smoking spontaneously due to loss of the desire to smoke. No serious side effects were reported by patients in either group. Table 1. Variables at each visit (Mean (S.D.)). Time Baseline Week 2 Month 1 Month 3 Dependent measures rTMS Sham rTMS Sham rTMS Sham rTMS Sham BART 29.7 (18.2) 26.3 (16.1) 32.5 (24.9) 37.4 (12) 34.2 (12.1) 36.7 (8) BPDSI 19.9 (6.6) 24.06 (11.3) 15 (4.5) 22.1 (9.7) 14 (6.5) 20.6 (12.6) MADRS 16.4 (7.2) 18.7 (14.8) 15.8 (7.1) 12.7 (6.9) 19.6 (5.8) 15 (8.7) 14.4 (11.5) 25.2 (15.2) SCL-90 118.8 (71.1) 149.7 (59.6) 73.6 (24) 86.5 (54.4) 86.4 (21.7) 121 (73.5) 89.2 (45.1) 143.2 (94.5) GAS 68.2 (11.3) 73 (19.1) 69.6 (18) 63 (22.8) No statistical differences. BART: Balloon Analog Risk Task; BPDSI: Borderline Personality Disorder Severity Index; MADRS: Montgomery and Åsberg Rating Scale; SCL-90: Symptom Check-List 90 items; and GAS: Global Assessment Scale. Table options Table 2. Mean number of moves per Tower of London test (standard deviation) at each of the 5 visits per allocation group. Baseline 1 2 3 4 5 6 7 8 rTMS 1⁎ 2⁎ 3.1 (0.2) 4.1 (0.2) 4⁎ 5.7 (0.3) 5.5 (0.4) 8⁎ Sham rTMS 1⁎ 2⁎ 3⁎ 4.1 (0.3) 4⁎ 5.8 (0.3) 5.2 (0.5) 8⁎ Week 2 1 2 3 4 5 6 7 8 rTMS 1⁎ 2⁎ 3.1 (0.2) 4.3 (0.3) 4.1 (0.2) 5.5 (0.3) 5.1 (0.2) 8⁎ Sham rTMS 1⁎ 2⁎ 3⁎ 4⁎ 4⁎ 5.6 (0.5) 5.4 (0.5) 7.9 (0.2) Month 1 1 2 3 4 5 6 7 8 rTMS 1⁎ 2⁎ 3⁎ 4.2 (0.3) 4⁎ 5.8 (0.2) 5.3 (0.3) 7.5 (0.4) Sham rTMS 1⁎ 2⁎ 3⁎ 4.1 (0.2) 4⁎ 5.6 (0.5) 5.4 (0.2) 7.6 (0.2) Month 3 1 2 3 4 5 6 7 8 rTMS 1⁎ 2⁎ 3⁎ 4.2 (0.3) 4.2 (0.4) 5.4 (4.3) 5.4 (0.2) 7.6 (0.2) Sham rTMS 1⁎ 2⁎ 3⁎ 4⁎ 4⁎ 5.7 (0.5) 5.3 (0.3) 7.8 (0.9) ⁎ For zero standard deviation.