TMS in the Treatment of Borderline Personality Disorder

Borderline personality disorder (BPD) is a common and often disabling condition. It is commonly seen in survivors of childhood physical, emotional, or sexual abuse. It is characterized by disturbances of attachment (intense and unstable relationships, fear of abandonment), emotional regulation (rapid and powerful mood swings, often into depression, anxiety, or anger) and sense of self (dissociation, not recognizing one’s own identity, and feelings of numbness or emptiness). Many people with BPD self-harm or make suicide attempts or threats. They often have difficulty managing their lives and relationships.

The symptoms of BPD often do not respond well to medications, perhaps because people with BPD are suffering from more of an environmental and psychological injury, as opposed to something more chemical and genetic. There are currently no medications that are FDA approved for BPD.

Transcranial Magnetic Stimulation, or TMS, is a cutting-edge treatment approved for major depression in 2008. It employs a pulsating magnetic field to stimulate (or sometimes inhibit) various areas of the brain. When used for depression, we typically stimulate the dorsolateral prefrontal cortex, an area of the brain involved in establishing conscious control over emotional impulses coming from deeper regions of the brain. This is very interesting when it comes to patients with BPD, because “control over emotional impulses” sounds almost tailor-made for some of their symptoms. However, it is important to note that TMS is also not approved for treatment of BPD.

TMS has, however, been looked at in a preliminary way in several studies on people with BPD. The gold-standard research—large, randomized, placebo-controlled studies—has yet to be done on TMS for BPD. However, three small sham-controlled studies (Feffer 2022, Cailhol 2014, Calderón-Moctezuma 2021) suggest efficacy, not just in terms of depression, but also in terms of other aspects of BPD, especially abandonment, affective issues, interpersonal relationships, suicidal behavior, anger, and paranoid ideation. Cognitive improvement was seen in decision-making.

Our experience is largely in keeping with these studies. We have seen a relatively large number of patients with BPD experience marked reductions in depression, as well as other symptoms such as emotional reactivity, anxiety, and suicidality. Whereas the presence of BPD is often seen as predicting a poor response to medication, we do not believe this is the case for TMS. We believe TMS should be considered earlier in clinicians’ algorithms for depressed BPD patients.

Long-term psychotherapy and dialectical behavior therapy (DBT) remain the mainstays of treatment for BPD. However, when patients with borderline personality disorder are experiencing problems with depression, and especially if they have failed a few medication trials, strong consideration should be given to a consultation with a TMS provider. It may help where all else has failed.

References

Cailhol, L., et al. Borderline personality disorder and rTMS: a pilot trial. Psychiatry Res. 2014 Apr 30;216(1):155-7. doi: 10.1016/j.psychres.2014.01.030. Epub 2014 Jan 30.

Calderón-Moctezuma, A. R., et al. Improvement in borderline personality disorder symptomatology after repetitive transcranial magnetic stimulation of the dorsomedial prefrontal cortex: preliminary results. Braz J Psychiatry. 2021 Feb 1;43(1):65-69. doi: 10.1590/1516-4446-2019-0591

Feffer, K., et al. Dorsomedial prefrontal rTMS for depression in borderline personality disorder: A pilot randomized crossover trial. J Affect Disord. 2022 Mar 15;301:273-280. doi: 10.1016/j.jad.2021.12.038. Epub 2021 Dec 20.