Supplementary Methods and Results

Methods

Participants

Forty-three female participants were recruited, 16 euthymic bipolar disorder (BD) patients, 13 borderline personality disorder (BPD) patients and 14 healthy controls. Participants were recruited through the CADE Clinic (www.cadeclinic.com) at Royal North Shore Hospital and via advertisements. The study was approved by the Human Research Ethics Committee at Royal

North Shore Hospital (Sydney, Australia) and all participants completed informed consent prior to participation. All participants underwent a structured clinical interview by the psychiatrist

(GSM) to determine whether they met DSM-IV criteria for BD or BPD and were currently euthymic. Healthy controls were also assessed to ensure the absence of unusual symptoms and any psychiatric history.

Participants who were not currently euthymic, hospital inpatients, abusing substances, or who had a history of traumatic head injury, neurological illness (eg, seizures or stroke), learning or developmental disorders, or were not proficient in English were excluded from the study. All participants were instructed to refrain from alcohol or recreational drug use 24 hours prior to the brain scan and from caffeine or nicotine within one hour of the scan.

Questionnaires

A series of questionnaires about mood, emotion regulation, childhood trauma, and schemas were administered: 1) The Depression Anxiety Stress Scales1 (DASS); 2) The Difficulties in Emotion

Regulation Scale2 (DERS); 3) The Emotion Amplification and Reduction Scale3 (TEARS); 4)

1 The Childhood Trauma Questionnaire4 (CTQ); 5) The NEO Five-Factor Inventory5, 6 (NEO-FFI) which measures the five main domains of personality; 6) the Self Report Manic Inventory7

(SRMI). The Weschler Test of Adult Reading8 (WTAR) was also administered as a measure of premorbid intelligence.

Behavioral Task

The emotional Stroop task was programmed using Presentation software

(http://www.neurobs.com). Participants viewed a series of 72 words (24 positive, 24 negative and 24 neutral) from the Affective Norms for English Words (ANEW) manual9. The emotional words were selected carefully so that they held semantic salience to each patient group and evoked powerful responses. Based on the ANEW norms for females9, the words were selected so that the mean valence for the negative, positive and neutral words were 2.0, 8.2, and 5.1, respectively. The level of arousal was comparable across positive and negative words with mean arousal ratings for negative, positive, and neutral words were 6.1, 6.3, and 3.8, respectively.

Further words were matched for number of syllables in each valence condition.

Words were displayed in a 16sec block consisting of eight words. Six blocks of each valence were presented, alternating with baseline blocks of non-words (****) over two functional runs.

Each word was presented for 1500ms, followed by an average 500ms (250-750ms) inter- stimulus interval (black screen). Words were not repeated, and the order of blocks was counterbalanced. Words and non-words were displayed in one of four colors red, blue, yellow and green and participants were instructed to indicate the color of the word as quickly and as accurately as possible by pressing one of four buttons. Reaction time and accuracy of responses were also obtained.

2 MRI data acquisition

Imaging datasets (structural and functional) were acquired on a 3T Siemens Magnetom Trio

Scanner at the Advanced Research and Clinical High-field Imaging (ARCHI) facility of the

University of Sydney. A T2*-weighted gradient echo echo planner imaging (EPI) sequence (29 axial slices, slice thickness 4mm with 1mm gap, TR=2000ms, TE=35ms, flip=70o, 64 × 64 matrix) was used to acquire functional data. A high resolution T1-weighted structural image was also acquired for precise localization of brain activity using a magnetisation prepared rapid gradient echo (MPRAGE) sequence (TR=1570ms, TE=3.22ms, Flip=15o, matrix 256 x 256, 192 slices). To minimize head movement during scanning, the head was restrained using foam pads inserted on each side. fMRI data analysis

Data analyses were carried out using SPM5 software

(http://www.fil.ion.ucl.ac.uk/spm/software/spm5). Each subject’s functional and structural images were first inspected visually for scanner artifacts and gross anatomical abnormalities, and then re-oriented so that the origin of the image lay within 3cm of the anterior commissure.

Functional images were realigned, corrected for slice time variation, and were spatially normalized to a common stereotactic space using the Montreal Neurological Institute (MNI) EPI template. Finally, the functional images were spatially smoothed with a Gaussian kernel of 8mm3 full width at half maximum.

3 Using the general linear model framework10, each experimental condition (positive, negative, and neutral) was modelled with a box-car function convolved with a canonical hemodynamic response function. In order to remove low-frequency confounds, data were high-pass filtered

(128sec) and temporal correlation was modelled using a first-order autoregressive model (AR1).

The experimental contrast was created by subtracting the neutral condition from the emotion

(positive + negative) condition and analysed in a subsequent random effects model.

Analyses were carried out within a priori anatomical regions of interest (ROIs). To investigate lateral and medial prefrontal neural activity the inferior, middle, superior, and medial prefrontal cortices including the anterior cingulate cortex (ACC) were chosen along with amygdala and hippocampus. Regional masks were created using the WFU_Pickatlas11.

In order to ensure that the Stroop task recruited ROIs, the experimental contrast (emot-neut) from all subjects was entered into a second level random effects analysis (one-sample t-test).

Activity was considered significant using a threshold of p < 0.05 (corrected for multiple comparisons using false discovery rate, FDR) and a cluster size of 20voxels. Differences between groups in ROI activity was determined using two-sample t-testsa one-way ANOVA, an uncorrected threshold of p < 0.05, and a cluster size of 20voxels.

Correlation Analyses

Percentage BOLD signal change during the presentation of emotional words compared to neutral words was calculated from the clusters of voxels where patient groups displayed similar and differential pattern of neural activity (such as in the right ventrolateral prefrontal cortex (vl-PFC), left dorsolateral prefrontal cortex (dl-PFC), medial prefrontal cortex (m-PFC), and amygdala

4 (Ag)) using the MarsBaR Toolbox (http://marsbar.sourceforge.net). These changes from all participants were then correlated with the total scores of DERS.

5 Clinical Data Analysis

Clinical data was analyzed using PASW Statistics Version 19. A series of One-Way Analyses of

Variance (ANOVA) for continuous data was used to compare the BD, BPD, and healthy control groups. Potential confounds such as age, years of education, premorbid IQ, childhood trauma history, and number of psychiatric medications, were explored first and then differences between groups on self-report measures of mood, emotional dysregulation, and personality were examined.

Where significant results of ANOVA were found, post-hoc analyses were conducted and the

Scheffè procedure was applied for multiple comparisons. An initial alpha level of 0.05 was used for all statistical tests.

6 Results

Demographic

Table 1: ANOVA results for demographic data and questionnaires.

Healthy BPD BD Controls Statistics Measure Mean (SD) Mean (SD) Mean (SD) F-Statistic p-value

Age (years) 32(7.9) 35.6(10.7) 31.2(11.1) F(2,40) = .84 0.439

Years of Education 14.6(2.4) 15.9(1.5) 15.4(1.9) F(2,39) = 1.44 0.249

Number Psychiatric Meds 1.4(1.2) 1.6(1.1) 0(0) F(2,42) = 11.47 0.000

WTAR Standard Score 116(5.8) 117(6.9) 117(5.7) F(2,38) = .16 0.376

CTQ (Total Score) 54.8(6.7) 55.4(8.5) 51.3(7.0) F(2,37) = .86 0.755

Questionnaires

DASS Total Score 26.5 (12.4) 15.0 (9.7) 6.8 (5.1) F(2, 40) = 14.33 0.000

DASS Depression 9.7 (6.7) 4.4 (4.8) 2.1 (2.7) F(2, 40) = 8.26 0.000

Neuroticism 38.1(8.9) 30.6 (4.8) 17.4 (6.2) F(2, 37) = 25.56 0.000

DERS Total Score 130.0 (18.6) 89.6 (19.6) 68.8 (17.5) F(2, 40) = 37.9 0.000

TEARS Total Score 37.6 (7.7) 43.8 (6.9) 47.8 (7.6) F(2, 40) = 6.61 0.003

SRMI Total Score 16.2 (5.1) 11.2 (8.6) 8.9 (6.7) F(2, 40) = 3.87 0.029

7 fMRI Findings:

Table 2: Summary of brain regions where bipolar disorder (BD) and borderline personality disorder (BPD) patients displayed different neural activity compared to healthy controls (HC).

Cluster MNI co-ords voxel Regions Size x,y,z (mm) equivZ Healthy Controls (HC) vs Bipolar Patients (BD) HC> BD Frontal regions -32 46 4-30, dl-PFC extending to vl-PFC 263274 46, 18 2.682.56 -28 - 4 44-36, dl-PFC 17163 44, 40 2.942.11

BD> HC Frontal regions -16 44 30-16, dm-PFC 156159 44, 30 2.892.7 12 50 30 12, 67115 50, 30 2.142.61 46 36 -1048, vl-PFC 9073 36, -12 2.492.29 Healthy Controls (HC) vs Borderline Patients (BPD)

HC> BPD Frontal regions -34 34 34-32, dl-PFC 452409 34, 34 3.453.11 34 38 3832, 40 139143 36 2.282.26 Limbic regions 36 -18 -2026, Ag extending to Hi 98100 -8, -14 2.912.73

BPD> HC Frontal regions vl-PFC 10299 44 36 -844, 2.62.68

8 38, -8 -42 38 -6-44, 329284 38, -6 2.562.32

Abbreviation Used: Prefrontal Cortex (PFC), dorsolateral (dl), ventrolateral (vl), dorsomedial

(dm), Amygdala (Ag), Hippocampus (Hi)

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