Amygdala neurofeedback as an adjunct to residential dialectical behavior therapy for borderline personality disorder: a pilot randomized controlled trial

BACKGROUND: Borderline personality disorder (BPD) is characterized by affective instability and amygdala hyperreactivity. Although dialectical behavior therapy (DBT) reduces symptoms and amygdala-related abnormalities, many patients show only partial remission. Real-time functional magnetic resonance imaging (fMRI) amygdala neurofeedback (amy-NF) directly targets hyperactive limbic responses and has shown promise in uncontrolled trials. We examined whether amy-NF adds benefit to inpatient DBT. METHODS: Thirty-six mid-therapy people with BPD and clinically significant residual symptoms (BSL-23 > 1.5) were randomized to DBT plus amy-NF (n = 23) or DBT alone, termed treatment as usual (TAU = 13). Post-treatment assessments were completed by 15/9 (amy-NF/TAU), with 15/8 and 12/7 completing the 3- and 6-month follow-ups. Ecological momentary assessment (EMA) of daily-life affective instability served as the primary outcome. Secondary outcomes included self-reports, amygdala responses during two fMRI tasks, and resting-state fMRI. Assessments occurred at pre-, post-, 3-, and 6-month follow-up. RESULTS: Participants successfully downregulated amygdala activity during neurofeedback. EMA showed improvements in negative affect, inner tension, and affective instability over time, without consistent superiority of amy-NF. Self-reports likewise showed no additional benefit of amy-NF, and BSL-23 scores increased after discharge in both groups. Amy-NF was associated with transient pre-post reductions in amygdala activity during both viewing and regulation in the emotion regulation task, and with more stable amygdala reactivity over time than TAU in the faces task. Resting-state analyses showed transient pre-post increases in amygdala connectivity with precuneus and dorsomedial frontal regions in amy-NF. CONCLUSIONS: Amygdala neurofeedback is feasible and reduced amygdala activity in BPD, but did not yield additional clinical benefit when delivered alongside intensive residential DBT, although the small sample may have limited power to detect such effects. TRIAL REGISTRATION: The study protocol was preregistered 2020/03/26 on ClinicalTrials.gov and received the ID NCT04333888.