Relationship between depression and borderline personality disorder

Borderline personality disorder features are associated with inflexible social interpretations

BACKGROUND

Borderline personality disorder (BPD) is thought to involve aberrant social learning, including impaired revision of social interpretations with new evidence (social interpretation inflexibility). However, this topic has received little empirical attention outside of specific literatures, such as moral inference or behavioral economics. Further, the contribution of comorbid depression to BPD-related interpretation inflexibility has not yet been assessed.

METHODS

In two independent samples (Study 1: N = 213; Study 2: N = 210, oversampled for BPD features), we assessed the associations between BPD symptoms, depressive symptoms, and task-based measures of social interpretation flexibility.

RESULTS

We found that BPD symptoms, particularly volatility of identity and relationships, were associated with less revision of social interpretations with both positive and negative evidence. Meanwhile, depressive symptoms were associated with a pattern of less revision of social interpretations with positive versus negative information.

LIMITATIONS

The use of cross-sectional, crowdsourced samples limits causal interpretations. Translation to clinical populations should be assessed in future studies.

CONCLUSIONS

Results suggest that inflexible social interpretations across valences may be a feature of BPD-related pathology, and could be connected to symptoms involving volatility in social contexts. Future studies should investigate whether treatments geared toward increasing the flexibility of social interpretations are effective in treating BPD symptoms, especially those involving interpersonal difficulties.

Parental identity formation in mothers is linked to borderline and depressive symptoms: A person-centered analyses

The formation of a stable parental identity is an important developmental task which parents face. Difficulties in this process can significantly decrease the quality of life and hinder the fulfillment of the parental role. The present study analyzed whether parental identity status, based on the three identity processes from the Meeus-Crocetti model, is related to the severity of borderline and depressive symptoms. Four hundred and fifty-nine mothers aged 18-40 (M = 32.41, SD = 5.09) participated in the cross-sectional study. The results of the cluster analysis revealed the existence of five different parental identity statuses: Achievement, Foreclosure, Searching moratorium, Diffussion, and Moratorium. Significant differences were also observed between parents with different statuses in terms of borderline and depressive symptoms. The study confirmed predictions that mental health difficulties among parents co-occur with low identification with parenthood.

Efficacy and tolerability of Brain Stimulation interventions in Borderline Personality Disorder: state of the art and future perspectives - A systematic review

Treating Borderline Personality Disorder (BPD) is a major challenge for psychiatrists. As Brain Stimulation represents an alternative approach to treat psychiatric disorders, our systematic review is the first to focus on both invasive and Non-Invasive Brain Stimulation (NIBS) interventions in people living with BPD, examining clinical effects over core features and comorbid conditions. Following PRISMA guidelines, out of 422 original records, 24 papers were included regarding Deep Brain Stimulation (n = 1), Electroconvulsive therapy (n = 5), Transcranial Magnetic Stimulation (n = 13) and transcranial Direct Current Stimulation (n = 5). According to impulsivity and emotional dysregulated domain improvements, NIBS in BPD appears to restore frontolimbic network deficiencies. NIBS seems also to modulate depressive features. Safety and tolerability profiles for each technique are discussed. Despite encouraging results, definitive recommendations on Brain Stimulation in BPD are mitigated by protocols heterogeneity, lack of randomized controlled trials and poor quality of included studies, including high risk of methodological biases. To serve as guide for future systematic investigations, protocols optimization proposals are provided, focusing on alternative stimulation sites and suggesting a NIBS symptom-based approach.

Structural Features Related to Affective Instability Correctly Classify Patients With Borderline Personality Disorder. A Supervised Machine Learning Approach

Previous morphometric studies of Borderline Personality Disorder (BPD) reported inconsistent alterations in cortical and subcortical areas. However, these studies have investigated the brain at the voxel level using mass univariate methods or region of interest approaches, which are subject to several artifacts and do not enable detection of more complex patterns of structural alterations that may separate BPD from other clinical populations and healthy controls (HC). Multiple Kernel Learning (MKL) is a whole-brain multivariate supervised machine learning method able to classify individuals and predict an objective diagnosis based on structural features. As such, this method can help identifying objective biomarkers related to BPD pathophysiology and predict new cases. To this aim, we applied MKL to structural images of patients with BPD and matched HCs. Moreover, to ensure that results are specific for BPD and not for general psychological disorders, we also applied MKL to BPD against a group of patients with bipolar disorder, for their similarities in affective instability. Results showed that a circuit, including basal ganglia, amygdala, and portions of the temporal lobes and of the orbitofrontal cortex, correctly classified BPD against HC (80%). Notably, this circuit positively correlates with the affective sector of the Zanarini questionnaire, thus indicating an involvement of this circuit with affective disturbances. Moreover, by contrasting BPD with BD, the spurious regions were excluded, and a specific circuit for BPD was outlined. These results support that BPD is characterized by anomalies in a cortico-subcortical circuit related to affective instability and that this circuit discriminates BPD from controls and from other clinical populations.

Stimulus valence, episodic memory, and the priming of brain activation profiles in borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is characterized by instability in affective regulation that can result in a loss of cognitive control. Triggers may be neuronal responses to emotionally valenced context and/or stimuli. 'Neuronal priming' indexes the familiarity of stimuli, and may capture the obligatory effects of affective valence on the brain's processing system, and how such valence mediates responses to the repeated presentation of stimuli. We investigated the effects of affective valence of stimuli on neuronal priming (i.e. changes in activation to repeated presentation of stimuli), and if these effects distinguished BPD patients from controls.

METHODS

Forty BPD subjects and 25 control subjects (age range: 18-44) participated in an episodic memory task during fMRI. Stimuli were presented in alternating epochs of encoding (six images of positive, negative, and neutral valence) and recognition (six images for 'old' v. 'new' recognition). Analyses focused on inter-group differences in the change in activation to repeated stimuli (presented during Encoding and Recognition).

RESULTS

Relative to controls, BPD showed greater priming (generally greater decrease from encoding to recognition) for negatively valenced stimuli. Conversely, BPD showed less priming for positively valenced stimuli (generally greater increase from encoding to recognition).

CONCLUSION

Plausibly, the relative familiarity of negative valence to patients with BPD exerts an influence on obligatory responses to repeated stimuli leading to repetition priming of neuronal profiles. The specific effects of valence on memory and/or attention, and consequently on priming can inform the understanding of mechanisms of altered salience for affective stimuli in BPD.

Common and different gray and white matter alterations in bipolar and borderline personality disorder: A source-based morphometry study

According to the nosological classification, Bipolar Disorder (BD) and Borderline Personality Disorder (BPD) are different syndromes. However, these pathological conditions share a number of affective symptoms that make the diagnosis difficult. Affective symptoms range from abnormal mood swings, characterizing both BD and BPD, to regulation dysfunctions, more specific to BPD. To shed light on the neural bases of these aspects, and to better understand differences and similarities between the two disorders, we analysed for the first time gray and white matter features of both BD and BPD. Structural T1 images from 30 patients with BD, 20 with BPD, and 45 controls were analysed by capitalizing on an innovative whole-brain multivariate method known as Source-based Morphometry. Compared to controls, BD patients showed increased gray matter concentration (p = .003) in a network involving mostly subcortical structures and cerebellar areas, possibly related to abnormal mood experiences. Notably, BPD patients showed milder alterations in the same circuit, standing in the middle of a continuum between BD and controls. In addition to this, we found an altered white matter network specific to BPD (p = .018), including frontal-parietal and temporal regions possibly associated with dysfunctional top-down emotion regulation. These findings may shed light on a better understanding of affective disturbances behind the two disorders, with BD patients more characterized by abnormalities in neural structures involved in mood oscillations, and BPD by deficits in the cognitive regulation of emotions. These results may help developing better treatments tailored to the specific affective disturbances displayed by these patients.

Evidence for default mode network dysfunction in borderline personality disorder

BACKGROUND

Although executive and other cognitive deficits have been found in patients with borderline personality disorder (BPD), whether these have brain functional correlates has been little studied. This study aimed to examine patterns of task-related activation and de-activation during the performance of a working memory task in patients with the disorder.

METHODS

Sixty-seven DSM-IV BPD patients and 67 healthy controls underwent fMRI during the performance of the n-back task. Linear models were used to obtain maps of within-group activations and areas of differential activation between the groups.

RESULTS

On corrected whole-brain analysis, there were no activation differences between the BPD patients and the healthy controls during the main 2-back v. baseline contrast, but reduced activation was seen in the precentral cortex bilaterally and the left inferior parietal cortex in the 2-back v. 1-back contrast. The patients showed failure of de-activation affecting the medial frontal cortex and the precuneus, plus in other areas. The changes did not appear to be attributable to previous history of depression, which was present in nearly half the sample.

CONCLUSIONS

In this study, there was some, though limited, evidence for lateral frontal hypoactivation in BPD during the performance of an executive task. BPD also appears to be associated with failure of de-activation in key regions of the default mode network.

The serotonin transporter gene polymorphism (5-HTTLPR) and affective symptoms among women diagnosed with borderline personality disorder

Gene variants of the serotonin transporter have been associated with vulnerability to affective disorders. In particular, the presence of one or two copies of the short (s) allele of the 5-HTTLPR polymorphism has been associated with reduced serotonin transporter expression and function, and vulnerability to affective disorders. To test for an association between variants of the serotonin transporter gene polymorphism (5-HTTLPR) and relevant clinical features of borderline personality disorder (BPD), a psychiatric disorder with symptoms characteristic for serotonin dysfunction, 77 women with BPD were genotyped in the 5-HTTLPR polymorphism. They rated their subjective experience of borderline-specific, depressive, anxious and obsessive-compulsive symptoms, and were interviewed about lifetime incidence of suicide attempts and self-harming acts. Carriers of two s alleles of the 5-HTTLPR reported more symptoms of borderline, depression, anxiety and obsessive-compulsive behaviours, but not of suicidal and self-injury behaviour, compared to carriers of a long (l) allele. This indicates that the 5-HTTLPR ss homozygous genotype might influence serotonin function affecting susceptibility to both borderline-specific, depressive, anxious and obsessive-compulsive symptoms in BPD, and leading to a more severe symptomatology related to these clinical features. Further, this suggests that 5-HTT gene variants may not be as influential on suicidal and self-injury behaviour in BPD.

Depression predicts interpersonal problems partially through the attitude towards social touch

INTRODUCTION

Depression is associated with difficulties in interpersonal relationships, of which communication is an integral part. Communication can not only be effected by verbal means, but also non-verbally by touch. Against this background, the aim of the present study was to investigate the relationship between depression, interpersonal problems and the attitude towards social touch.

METHODS

147 individuals (115 females; 21-71 years old) seeking treatment in a clinic for outpatient psychotherapy took part in the survey. Three questionnaires evaluating the level of depression (Beck Depression Questionnaire), the degree of interpersonal problems (Inventory of Interpersonal Problems) and the attitude towards social touch (Social Touch Questionnaire, were administered.

RESULTS

Highly depressed individuals had a more negative attitude towards social touch than non-to lowly depressed individuals. Highly depressed individuals particularly reported to dislike physical touch by not well-known people, but not by close ones. Highly depressed individuals also reported more interpersonal problems, with the level of depression predicting the degree of interpersonal problems. This relationship was partially mediated by the attitude towards social touch in general and, to a greater extent, by the dislike of physical touch by people not well-known in particular.

DISCUSSION

Given the role of social touch in the relationship between depression and interpersonal problems, the attitude towards touch may be taken into consideration in the therapy of depressed patients. We assume that a more positive attitude towards social touch can influence the ability to create and maintain interpersonal relationships.

Common and distinct patterns of abnormal cortical gyrification in major depression and borderline personality disorder

Abnormal gray matter volume has been consistently reported in patients with major depressive disorder (MDD), but markers of cortical neurodevelopment have been rarely investigated. Also, it is unclear whether there exist common versus distinct spatial patterns of abnormal cortical development across different disorders presenting with negative emotions and deficient affective regulation. In this study, we used structural MRI at 3T to investigate the local gyrification index (LGI), a marker of fetal/infant neurodevelopment, in adult female patients with MDD (n = 22), in adult female patients with borderline personality disorder (BPD) (n = 17), and in controls (n = 22). Reduced cortical folding of the precuneus, the superior parietal gyrus and the parahippocampal gyrus was found in both MDD and BPD patients when compared to controls (p < 0.05, cluster-wise probability [CWP] corrected). MDD patients showed additional hypogyrification of the middle frontal gyrus and the fusiform gyrus when compared to both controls and BPD patients (p < 0.05, CWP corrected). In MDD patients, lower LGI of prefrontal regions was significantly associated with the age of disease onset and with the number of depressive episodes. In BPD patients, lower LGI of orbitofrontal regions was associated with impulsivity. Our findings suggest abnormal early cortical development in MDD, affecting brain regions that have been frequently implied in MDD pathophysiology. However, LGI abnormalities may not be specific for MDD, since MDD and BPD patients also exhibited common patterns of hypogyrification. Hypogyrification of cortical regions associated with higher-order cognition appears to be most pronounced in MDD. Abnormal early cortical neurodevelopment may mediate vulnerability to disorders of emotion.

Abnormalities in gray matter volume in patients with borderline personality disorder and their relation to lifetime depression: A VBM study

Background

Structural imaging studies of borderline personality disorder (BPD) have found regions of reduced cortical volume, but these have varied considerably across studies. Reduced hippocampus and amygdala volume have also been a regular finding in studies using conventional volumetric measurement. How far comorbid major depression, which is common in BPD and can also affect in brain structure, influences the findings is not clear.

Methods

Seventy-six women with BPD and 76 matched controls were examined using whole-brain voxel-based morphometry (VBM). The hippocampus and amygdala were also measured, using both conventional volume measurement and VBM within a mask restricted to these two subcortical structures. Lifetime history of major depression was assessed using structured psychiatric interview.

Results

At a threshold of p = 0.05 corrected, the BPD patients showed clusters of volume reduction in the dorsolateral prefrontal cortex bilaterally and in the pregenual/subgenual medial frontal cortex. There was no evidence of volume reductions in the hippocampus or amygdala, either on conventional volumetry or using VBM masked to these regions. Instead there was evidence of right-sided enlargement of these structures. No significant structural differences were found between patients with and without lifetime major depression.

Conclusions

According to this study, BPD is characterized by a restricted pattern of cortical volume reduction involving the dorsolateral frontal cortex and the medial frontal cortex, both areas of potential relevance for the clinical features of the disorder. Previous findings concerning reduced hippocampus and amygdala volume in the disorder are not supported. Brain structural findings in BPD do not appear to be explainable on the basis of history of associated lifetime major depression.

Disorder-specific characteristics of borderline personality disorder with co-occurring depression and its comparison with major depression: An fMRI study with emotional interference task

Borderline personality disorder (BPD) and major depressive disorder (MDD) are both associated with abnormalities in the regulation of emotion, with BPD being highly comorbid with MDD. Disorder-specific dysfunctions in BPD, however, have hardly been addressed, hence the lack of knowledge pertaining to the specificity of emotion processing deficits and their commonality with MDD.

24 healthy comparison subjects, 21 patients with MDD, and 13 patients with comorbid BPD and MDD (BPD + MDD group) were studied using functional MRI. The subjects were required to perform an emotional interference task that entailed categorizing facial affect while ignoring words that labeled the emotional contents of the external stimuli.

Collapsing across emotional face types, we observed that participants with BPD + MDD uniquely displayed a greater involvement of the visual areas and the cerebellum. During emotional conflict processing, on the other hand, the lateral prefrontal cortex (LPFC) appeared to be affected in both patient groups. In comparison to the HC, the MDD group showed differences also in the posterior medial frontal cortex (pMFC) and the inferior parietal lobule (IPL).

Thus, our data indicate dysfunctionality in the neural circuitry responsible for emotional conflict control in both disorders. The enhanced visual cortex activation in BPD + MDD suggests the visual system's hyperresponsiveness to faces at an early perceptual level. Not being associated with co-occurring depression, this effect in BPD + MDD appears to represent specific personality traits such as disturbed reactivity toward emotionally expressive facial stimuli.

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24 healthy controls, 21 patients with MDD, and 13 patients with BPD + MDD were studied using fMRI

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During emotional conflict processing, the lateral prefrontal cortex (LPFC) was affected in both patient groups

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BPD + MDD group uniquely displayed a greater involvement of the visual areas and the cerebellum

Common and distinct structural network abnormalities in major depressive disorder and borderline personality disorder

Major depressive disorder (MDD) and borderline personality disorder (BPD) show substantial overlap in both affective symptom expression and in regional brain volume reduction. To address the specificity of structural brain change for the respective diagnostic category, we investigated structural networks in MDD and BPD to identify shared and distinct patterns of abnormal brain volume associated with these phenotypically related disorders. Using magnetic resonance imaging at 3 T, we studied 22 females with MDD, 17 females with BPD and without comorbid posttraumatic stress disorder, and 22 age-matched female healthy controls. We used “source-based morphometry” (SBM) to investigate naturally grouping patterns of gray matter volume variation (i.e. “structural networks”) and the magnitude of their expression between groups. SBM identified three distinct structural networks which showed a significant group effect (p b 0.05, FDR-corrected). A bilateral frontostriatal network showed reduced volume in MDD compared to both controls and BPD patients. A medial temporal/medial frontal network was found to be significantly reduced in BPD compared to both controls and MDD patients. Decreased cingulate and lateral prefrontal volume was found in both MDD and BPD when compared to healthy individuals. In MDD significant relationships were found between depressive symptoms and a cingulate/lateral prefrontal structural pattern. In contrast, overall BPD symptoms and impulsivity scores were significantly associated with medial temporal/medial frontal network volume. The data suggest both distinct and common patterns of abnormal brain volume in MDD and BPD. Alterations of distinct structural networks differentially modulate clinical symptom expression in these disorders.

Acoustic Emotional Processing in Patients With Borderline Personality Disorder: Hyper- or Hyporeactivity?

Earlier studies have demonstrated emotional overreactions to affective visual stimuli in patients with borderline personality disorder (BPD). However, contradictory findings regarding hyper- versus hyporeactivity have been reported for peripheral physiological measures. In order to extend previous results, the authors investigated emotional reactivity and long-term habituation in the acoustic modality. Twenty-two female BPD patients and 19 female nonclinical controls listened to emotionally negative, neutral, and positive sounds in two identical sessions. Heart rate, skin conductance, zygomaticus/corrugator muscle, and self-reported valence/arousal responses were measured. BPD patients showed weaker skin conductance responses to negative sounds than controls. The elevated zygomaticus activity in response to positive sounds observed in controls was absent in BPD patients, and BPD patients assigned lower valence ratings to positive sounds than controls. In Session 2, patients recognized fewer positive sounds than controls. Across both groups, physiological measures habituated between sessions. These findings add to growing evidence toward partial affective hyporeactivity in BPD.

Borderline personality disorder in transition age youth with bipolar disorder

OBJECTIVE

To determine the longitudinal impact of borderline personality disorder (BPD) on the course and outcome of bipolar disorder (BP) in a pediatric BP sample.

METHOD

Participants (N = 271) and parents from the Course and Outcome of Bipolar Youth (COBY) study were administered structured clinical interviews and self-reports on average every 8.7 months over a mean of 93 months starting at age 13.0 ± 3.1 years. The structured interview for DSM-IV personality disorders (SIDP-IV) was administered at the first follow-up after age 18 to assess for symptoms of BPD. BPD operationalized at the disorder, factor, and symptom level, was examined as a predictor of poor clinical course of BP using all years of follow-up data.

RESULTS

The number of BPD symptoms was significantly associated with poor clinical course of BP, above and beyond BP characteristics. Affective dysregulation was most strongly associated with poor course at the factor level; the individual symptoms most strongly associated with poor course were dissociation/stress-related paranoid ideation, impulsivity, and affective instability.

CONCLUSION

BPD severity adds significantly to the burden of BP illness and is significantly associated with a more chronic and severe course and outcome beyond what can be attributable to BP characteristics.

Specificity of abnormal brain volume in major depressive disorder: a comparison with borderline personality disorder

BACKGROUND

Abnormal brain volume has been frequently demonstrated in major depressive disorder (MDD). It is unclear if these findings are specific for MDD since aberrant brain structure is also present in disorders with depressive comorbidity and affective dysregulation, such as borderline personality disorder (BPD). In this transdiagnostic study, we aimed to investigate if regional brain volume loss differentiates between MDD and BPD. Further, we tested for associations between brain volume and clinical variables within and between diagnostic groups.

METHODS

22 Females with a DSM-IV diagnosis of MDD, 17 females with a DSM-IV diagnosis of BPD and without comorbid posttraumatic stress disorder, and 22 age-matched female healthy controls (HC) were investigated using magnetic resonance imaging. High-resolution structural data were analyzed using voxel-based morphometry.

RESULTS

A significant (p<0.05, cluster-corrected) volume decrease of the anterior cingulate cortex (ACC) was found in MDD compared to HC, as opposed to volume decreases of the amygdala in BPD compared to both HC and MDD. Sensitivity and specificity of regional gray matter volume for a diagnosis of MDD were modest to fair. Amygdala volume was related to depressive symptoms across the entire patient sample.

LIMITATIONS

Potential limitations of this study include the modest sample size and the heterogeneous psychotropic drug treatment.

CONCLUSIONS

ACC volume reduction is more pronounced in MDD with an intermediate degree of volume loss in BPD compared to HC. In contrast, amygdala volume loss is more pronounced in BPD compared to MDD, yet amygdala volume is associated with affective symptom expression in both disorders.

Personality disorders and the persistence of substance use disorders: A reanalysis of published NESARC findings

The purpose of this study was to examine whether published findings regarding the association of personality disorders (PDs) with the persistence of substance use disorders (SUDs) are attributable to an artifact due to time of assessment of the PD. Two previous studies analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and found that Antisocial PD, Schizotypal PD, and Borderline PD are unique predictors of SUDs. However, a design limitation in NESARC (assessment of PDs at different waves) can potentially compromise these findings. To assess the influence of time of assessment of PDs and to identify associations that might be robust to time of assessment, we compared the association of PDs with 2 estimates of SUD persistence that were based on different populations at risk: (a) among those who were diagnosed with SUD at baseline, the proportion who continued to meet full criteria at follow-up ("prediction"); and (b) among those who were diagnosed with SUD at follow-up, the proportion who met full criteria at baseline ("postdiction"). Differences between prediction and postdiction revealed a robust pattern of higher odds ratios for postdiction among PDs assessed at baseline, and lower odds ratios for postdiction among PDs assessed at follow-up. All published significant associations between PDs and persistence of SUDs became nonsignificant in the postdiction analyses, with the exception of obsessive-compulsive PD predicting nicotine dependence persistence. The present results raise serious doubts about the validity of published findings on PDs and SUD persistence from the NESARC. Design limitations in NESARC preclude a direct comparison among PDs measured at different waves.

Depression in patients with borderline personality disorder

Borderline personality disorder (BPD) and major depressive disorder (MDD) commonly co-occur, but the relationship between these disorders remains unclear. While BPD patients often suffer from depression, their subjective experience and treatment response are different from that experienced by MDD patients without BPD. Surveying the current literature on the interface of these two pathologies, we find that depression in BPD has distinct symptoms, treatment responses, remission predictors, and suicide risks. It tends to be subjectively more severe, more interpersonally fueled, and more persistent than MDD without BPD. BPD depression responds less well to biological treatments and may be fueled by the neurobiology of BPD. These findings suggest that clinicians should recognize the unique features of BPD depression and anticipate a clinical trajectory that may be different from MDD without BPD, keeping in mind that BPD depression tends not to improve until BPD improves.

Is the residential combined (psychotherapy plus medication) treatment of patients with severe personality disorder effective in terms of suicidality and impulsivity?

The aim of this study was to compare the effectiveness of combined treatment-medication plus psychodynamic psychotherapy-and psychodynamic psychotherapy alone on the outcome variables of suicidality and impulsivity in a population of adult inpatients with severe personality disorder (SPD). This is a naturalistic-empirical (observational) study under the conditions of clinical practice (an intensive specialized inpatient psychotherapeutic program [SIPP]). The sample consisted of 33 inpatients with SPD who were allocated to two subgroups (groups A and B). The patients in group A received psychodynamic psychotherapy and adjunctive pharmacotherapy, whereas the patients in group B received multimodal psychodynamic psychotherapy only. A statistically significant reduction in suicidality score was observed in the patients in group A, whereas a tendency for significant reduction in impulsivity score was observed in group B after the SIPP termination. Pharmacotherapy combined with multimodal psychodynamic psychotherapy, always within the SIPP, seems more effective in the case of suicidality rather than impulsivity.

Sleep and borderline personality disorder: a review

Sleep problems are very common among psychiatric patients. Borderline personality disorder, as a common and severe mental disorder, is associated with different types of sleep disturbances, such as disturbances of sleep continuity, altered REM sleep regulation and nightmares. These disturbances are the result of interaction of the personality traits, concomitant and comorbid diseases and environmental factors. Despite the high prevalence of sleep related disorders in BPD patients, this aspect of BPD is still neglected in clinical and research settings. To date there has been little agreement on sleep characteristics of BPD among different studies, and presence of some uncontrolled confounding factors, make interpretation of the results difficult. However, it seems that appropriate diagnosis and treatment of sleep disorders in BPD patients might lead to better outcome. This article aimed to review the current literature of sleep studies in BPD. Some recommendations and suggestions were made for future researches in this field.

Comorbidity between personality disorders and depressive symptomatology in women: A cross-sectional study of three different transitional life stages

This study assessed the prevalence of personality disorders (PDs), according to DSM-IV criteria, in relation to depressive symptomatology at three different periods of life in female subjects. Depressive symptoms and personality disorders were assessed in a sample of 568 women from three different transitional stages: 134 students, 314 primiparous women after childbirth and 120 women diagnosed with breast cancer. Depressive symptoms were assessed by the Hospital Depression and Anxiety Scale in the first and third groups and by the Edinburgh Post-natal Depression Scale in the second group, whereas PDs were assessed by the French version of the Vragenlijst voor Kenmerken van de Persoonlijkheid. Depressive symptomatology and rates of PD (20.4% and 6.3%) were equivalent in the three groups. The prevalence of PD was higher in the depressed group compared with the non-depressed group, with more paranoid, borderline, avoidant, obsessive-compulsive, schizotypal, antisocial, dependent and histrionic PD. Our findings support the hypothesis that PDs are more frequently associated with depressive symptoms. Borderline and avoidant PDs were more prevalent among young women. All cluster C PD (dependent, avoidant and obsessive-compulsive) co-occurred significantly with depressive symptoms.

The relationship between borderline personality disorder and major depression in later life: acute versus temperamental symptoms

OBJECTIVE

A recent issue in the personality disorder field is the prevalence and course of Axis II symptoms in later life. Focusing on the presentation of personality disorder criteria over time may have some utility in exploring the relationship between borderline personality disorder (BPD) and major depression in older adults. Temperamental personality symptoms are relatively resistant to change but tend to be nonspecific to disorders, whereas acute symptoms remit relatively quickly. We predicted that temperamental BPD symptoms would be positively correlated with a history of depression and did not expect to find a relationship between major depression and acute BPD symptoms.

METHODS

A total of 1,630 participants between the ages of 55 and 64 were recruited to participate in a community-based longitudinal study representative of the St. Louis area. Participants completed a battery of assessments at baseline, including diagnostic interviews for all 10 personality disorders and major depressive disorder.

RESULTS

Temperamental and acute BPD symptoms were significantly correlated with a history of major depression. After adjustments were made for the effects of temperamental symptoms on depression, acute symptoms were no longer correlated with a history of depression. As predicted, temperamental symptoms remained significantly related to depression, even after controlling for the effects of acute symptoms. BPD acute symptoms showed a unique negative correlation with the amount of time following remission from a depressive episode.

CONCLUSIONS

Overall, this study supports associations between major depression and borderline personality in older adults. The findings indicate that a history of major depression is primarily related to stable BPD symptoms related to emotional distress, which are more prevalent in older adults than acute features.

Differential diagnosis of bipolar affective disorder type II and borderline personality disorder: analysis of the affective dimension

BACKGROUND

Differential diagnosis between bipolar affective disorder type II and borderline personality disorder can be problematic yet a priority for effective treatment planning. Diagnosis is problematic when symptoms do not present enough intensity or duration to clear the issue but also when there is a relative overlap of criteria between both disorders. If for many patients, the diagnosis is more easily differentiated, confounding conditions are found in 20% of cases for which it becomes a significant issue.

METHOD

A research with the key words affective instability, borderline personality disorder, and bipolar disorder on Medline and Psych-Info was done. Other references were found through this review in related articles. Comparison of data about the affective dimensions concerning bipolar disorder and borderline personality disorder was noted.

RESULTS

Affective instability is a confounding factor: quality and intensity of affects, speed of fluctuations, affective response to social stress, and its modulation are core elements of affective instability that need to be analyzed to clarify a proper diagnosis.

LIMITATIONS

There is further necessity for research about affective instability in the 2 diagnoses.

CONCLUSIONS

Making a valid differential diagnosis has an important clinical value in order for the clinician to plan proper treatment. Analysis of the affective experience and its qualitative and quantitative facets can help establish it.

Platelet protein kinase C and brain-derived neurotrophic factor levels in borderline personality disorder patients

Borderline personality disorder (BPD) is a prevalent and difficult to treat psychiatric condition characterized by abrupt mood swings, intense anger and depression, unstable interpersonal relationships, impulsive self-destructive behavior and a suicide rate of approximately 10%. Possible underlying molecular dysregulations in BPD have not been well explored. Protein kinase C (PKC) and brain-derived neurotrophic factor (BDNF) have both been implicated in affective disorders, but their role in BPD has not been examined. Platelets were isolated from blood obtained from 24 medication-free BPD patients and 18 healthy control subjects. PKC-α, phosphorylated-PKC-α (p-PKCα), PKC-βII, and BDNF were measured in platelet homogenates by immunoblotting. In the males, platelet BDNF and PKC-α levels were lower in patients than controls. p-PKC-α and PKC-βII were lower at trend levels. In the entire sample, platelet p-PKCα and PKC-α activity were lower, at a trend level, in patients compared to controls. This is the first report to our knowledge of PKC and BDNF activity in BPD and calls for replication. These findings are consistent with altered PKC and BDNF activity in a range of neuropsychiatric conditions including bipolar disorder, depression and suicide.

Alexithymia in adolescents with borderline personality disorder

OBJECTIVE

The aim of this study was to explore the relationship between alexithymia and borderline personality disorder (BPD) in adolescents.

METHODS

The study investigated a sample of 59 consulting or inpatient adolescents with a well-established diagnosis of BPD (SIDP-IV) and a control sample of healthy adolescents individually matched by gender, age and socio-economic status. Alexithymia, depression and trait-anxiety were rated using the Twenty-item Toronto Alexithymia Scale (TAS-20), the Beck Depression Inventory (BDI-II) and the trait-anxiety subscale from the State-Trait Anxiety Inventory (STAI-T), respectively. A confirmatory factorial analysis (CFA) was performed to test the fit of the three-factor structure of the TAS-20 in the adolescent sample (N=140). BPD and control groups were compared on alexithymic scores using ANCOVA analyses controlling for the potential confounding effects of depression and anxiety.

RESULTS

The ratio of the chi-square to its degrees of freedom, the goodness-of-fit index, the adjusted goodness-of-fit index and Steiger's root-mean-square error of approximation had satisfactory values of 1.54; 0.87; 0.83 and 0.058, respectively. The two ANCOVA demonstrated no significant difference for TAS-20 scores. BPD subjects were more alexithymic than healthy subjects but this difference was mainly explained by the levels of depression or anxiety.

LIMITATIONS

Since BPD subjects have high comorbidity with depression or anxiety, longitudinal studies examining the absolute and relative stability of TAS-20 scores are necessary to determine whether alexithymia constitutes a state or a trait in BPD.

CONCLUSIONS

BPD adolescents are characterized by alexithymia, probably of a secondary or state-dependent nature.

Considering DSM-5: personality diagnostics in patients with schizophrenia spectrum disorders

The aims of this study were to examine the prevalence of personality disorders (PD) in patients with schizophrenia spectrum disorders (SSD), to examine the interaction of axis-I and axis-II symptoms to provide an estimate on the confounding potential of SSD psychopathology in the establishment of DSM-IV PD diagnoses, and to discuss implications concerning the proposed changes in DSM-5. Patients with SSD, aged 18 to 65 years, and being at least partially remitted (PANSS total score < 75) were included. PD was examined categorically and dimensionally using the SCID-II screening questionnaire and interview, and SSD psychopathology was rated using the Positive and Negative Syndrome Scale for Schizophrenia (PANSS). Forty-five patients (31 with schizophrenia) were included in the current study. Mean age was 37.2 years, and the median duration of illness was 9.5 years. Mean PANSS total score was 42.5. The cumulative prevalence of PD in our collective was 20%, with obsessive-compulsive, antisocial, and borderline PD being the most frequent. There were no cases of cluster A PD diagnoses. In the dimensional analysis, numerous correlations of small to medium effect size emerged between maladaptive personality traits and SSD psychopathology. PD is present in a clinically relevant subgroup of SSD patients and has to be recognized in SSD treatment. Currently, it remains unclear to what extent correlations between personality traits and SSD symptoms can be explained by content overlap or co-variation of SSD psychopathology and PD traits. SSD psychopathology may bias PD diagnostics and lead to a higher percentage of categorical PD diagnoses, especially considering the proposed changes in DSM-5.

Major depression and dimensional representations of DSM-IV personality disorders: a population-based twin study

BACKGROUND

Major depressive disorder (MDD) co-occurs frequently with personality disorders (PDs). The extent to which this results from shared genetic or environmental risk factors remains uncertain.

METHOD

Young adult twins (n=2801) from the population-based Norwegian Institute of Public Health Twin Panel were assessed at personal interview for DSM-IV lifetime MDD and the 10 Axis II PDs. The relationship between MDD and dimensional representations of all PDs was explored by stepwise logistic regression. Multivariate Cholesky twin models were fitted using the Mx program, and genetic and environmental correlations were estimated.

RESULTS

Dimensional representations of borderline (BPD), avoidant (AVPD) and paranoid personality disorder (PPD) were independently and significantly associated with increased risk for MDD. Multivariate twin modeling indicated that one latent factor accounted for the genetic covariance between MDD and the three PDs. The genetic correlations between MDD and dimensional representations of BPD, AVPD and PPD were +0.56, +0.22 and +0.40 respectively. No sex differences or shared environmental effects were found. The structure of the individual-specific environmental factors influencing MDD and the three PDs were similar to the genetic factors but the environmental correlations were lower: +0.39, +0.23 and +0.27 respectively.

CONCLUSIONS

There is substantial overlap between liability factors for MDD and BPD from cluster B, PPD from cluster A and AVPD from cluster C. The vulnerability to general PD pathology and MDD seem to be closely related. The patterns of co-morbidity observed between diverse psychiatric disorders might result from just a few liability factors.

The impact of comorbid dysthymic disorder on outcome in personality disorders

OBJECTIVE

The goal of our study was to investigate the impact of dysthymic disorder (DD), a form of chronic depression, on naturalistic outcome in individuals with personality disorders (PDs).

METHOD

The Collaborative Longitudinal Personality Disorders Study is a cohort initially including 573 subjects with 4 targeted PDs (borderline, avoidant, schizotypal, and obsessive-compulsive) and 95 subjects with major depression but no PD. At baseline, 115 subjects were diagnosed with coexisting DD, of whom 109 (94.8%) were PD subjects. Regression analyses were performed to predict 3 classes of broad clinical outcome after 2 years of prospective follow-up. We hypothesized that DD diagnosis at baseline would be associated with worse outcome on (1) persistence of a PD diagnosis, (2) impairment in psychosocial functioning (as measured by the Longitudinal Interval Follow-up Evaluation), and (3) crisis-related treatment utilization.

RESULTS

Baseline DD diagnosis was associated with persistence of PD diagnosis at 2 years, particularly for borderline and avoidant PDs. It was associated with worse outcome on global social adjustment, life satisfaction, recreation, and friendships, but not employment or relationship with spouse. Contrary to expectation, DD did not increase suicide attempts, emergency room visits, or psychiatric hospitalizations.

CONCLUSIONS

Comorbidity of DD is associated with persistence of PD diagnosis and with worse outcome on many, but not all, measures of psychosocial functioning.

Hypomanic symptoms predict an increase in narcissistic and histrionic personality disorder features in suicidal young adults

Consistent with the "scar hypothesis", according to which mood depression might impact personality, we examined the effect of unipolar and hypomanic mood disturbances on cluster B (i.e., narcissistic, histrionic, and borderline) personality disorder features. Data from 113 suicidal young adults were utilized, and cross-lagged associations between unipolar and hypomanic mood disturbances and cluster B personality disorder features were examined using manifest-variable structural equation modeling (SEM). Hypomanic symptoms predicted an increase in narcissistic and histrionic personality disorder features over the Time 1-Time 2 period, as well as an increase in narcissistic personality disorder features over the Time 1-Time 3 period. Unipolar depressive symptoms and borderline features were reciprocally and longitudinally associated, albeit at different time periods. The sample distinct features restrict generalization of the findings. An exclusive use of self-report measures might have contributed to shared method variance. Results are consistent with the notion that hypomanic symptoms increase narcissistic personality disorder tendencies.

Borderline personality disorder and mood spectrum

Several lines of evidence have raised the question of whether Borderline Personality Disorder (BPD) is an independent disease entity or it might be better conceptualized as belonging to the spectrum of mood disorders. This study explores a wide array of lifetime mood features (mood, cognitions, energy, and rhythmicity and vegetative functions) in patients with BP and mood disorders. The sample consisted of 25 BPD patients who did not meet the criteria for bipolar disorders, 16 bipolar disorders patients who did not meet the criteria for BPD, 19 unipolar patients who did not meet the criteria for BPD, and 30 non-clinical subjects. Clinical diagnoses were determined by administering the structured clinical interviews for DSM-IV disorders. The Mood Spectrum Self-Report (MOODS-SR) was used for measuring lifetime mood phenomenology. Clinical subjects displayed higher mean scores than normal subjects in all domains of the MOODS-SR, and BPD patients displayed higher scores than unipolar patients in the Mood and Cognition depressive subdomains. Differences between patients with BP and bipolar disorders on MOODS psychopathology did not attain statistical significance for any (sub)domain considered. The results of this study are consistent with previous findings suggesting the importance of mood dysregulations in patients with BPD.

Revisiting the structure of mental disorders: borderline personality disorder and the internalizing/externalizing spectra

OBJECTIVE

Researchers have turned to dimensional models of psychopathology as a means of explaining robust patterns of comorbidity. A hierarchical model consisting of internalizing and externalizing dimensions has been a useful approach to understanding comorbidity among some mental disorders, although a limited number of disorders have been examined within this framework. The objective of the present study is to determine how borderline personality disorder fits into this framework.

DESIGN AND METHODS

Dimensional measures of nine psychiatric disorders were used in a confirmatory factors analysis to compare five models of comorbidity in 1,197 members (N=541 women) of a population-based sample. Symptom composites were derived from the Michigan Composite International Diagnostic Interview and the International Personality Disorders Examination Questionnaire.

RESULTS

Five models were fit to dimensional indicators of nine disorders. A model in which borderline personality disorder served as a multidimensional indicator of the externalizing factor and the anxious-misery subfactor of internalizing disorders provided the best fit to the data in the whole sample and in men. For women, this model also fit well but an alternative model in which borderline personality disorder served only as an indicator of the anxious-misery subfactor of internalizing disorders fit equally well.

CONCLUSIONS

The present study demonstrates the utility of the internalizing/externalizing framework for characterizing personality disorders as well as Axis I disorders. Future work should explore how other personality disorders fit into this framework.

[Depression in borderline personality]

The author examines the impact of depression in borderline personality and attempts to explain its profound reasons from a psychoanalytical perspective. The psychic organization of the borderline personality predisposes to intense depressive affects. Being unable to come to a sufficiently harmonious psychic integration of life experiences and emotions, the individual conserves a divided and rigid organization of his internal world. The self is thus weakened and vulnerable, confused and defensive, what constitutes grounds for depressive affects. The diagnosis commands meticulous attention, because the borderline personality has tendency to project his difficult affects on people around him. It is often the therapist who first experiences the depression. The borderline personality's recourse to primitive defences renders him even more vulnerable and fragile in his interpersonal relationships and the failures are multiplied in his adaptation to the real world, education, work, personal relationship, etc. The author explains how the borderline personality has a particular way of entering in relation with people and situations. The borderline personality has a diffuse identity and does not distinguish well the borders between himself and the other. Thus, the borderline personality perceives the other more like an instrument to satisfy his own desires and needs. The other does not appear as similar and equal. His relational mode remains essentially narcissistic and his choices of objects as much as his identifications remain of narcissistic nature. This creates a confusion between a more or less important part of his Self and the other. Relational instability of the borderline personality entails breakups, losses that easily become sources of depression. The individual thus becomes lost, empty, depressed as if he was in fact losing an important part of himself.

Amygdala volume and depressive symptoms in patients with borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is characterized by a high prevalence of comorbid psychiatric disorders, including major depression (MD). The aim of this study was to examine whether a co-occurrence of MD is associated with structural changes in the amygdala of BPD patients.

METHODS

Twenty-five right-handed, female patients with BPD and 25 matched healthy control subjects were examined. Diagnoses of BPD and MD were made according to DSM IV. Depressive symptomatology was determined with the Hamilton Depression Scale (HAMD). Magnetic resonance imaging scans were performed with 1.5 T Magnetom Vision (Siemens, Erlangen, Germany). The software program "BRAINS" was applied for brain volumetry and segmentation. The amygdala was delineated as "region of interest."

RESULTS

Comparison of amygdala volumes between the whole group of BPD patients and control subjects revealed no significant difference. Amygdala volumes in both hemispheres were significantly larger in BPD patients with MD compared with those without MD. There was a significant correlation in BPD patients between left amygdala volume and depressive symptoms as measured by HAMD.

CONCLUSIONS

Correlation of amygdala volume with depression in BPD patients might indicate a causal relationship. Future studies should clarify whether amygdala enlargement is a risk factor for MD in BPD patients or a consequence of the affective disorder.

Cortisol, the cortisol-dehydroepiandrosterone ratio, and pro-inflammatory cytokines in patients with current major depressive disorder comorbid with borderline personality disorder

BACKGROUND

Major depression in young women is often comorbid with borderline personality disorder (BPD); however, adrenal steroids and pro-inflammatory cytokines in patients with comorbid current major depressive disorder and BPD (MDD/BPD) have not been systematically examined. Therefore, our study aimed at examining serum profiles of cortisol, cytokines, and the cortisol/dehydroepiandrosterone (cortisol/DHEA) ratio in MDD/BPD patients and a healthy comparison group.

METHODS

Twelve medication-free female patients with MDD/BPD and 12 healthy women were included. Serum profiles of cortisol, DHEA, tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and interleukin-1beta were sampled, and the molar cortisol/DHEA ratio was determined.

RESULTS

Concentrations of serum cortisol, TNF-alpha, and IL-6, as well as the cortisol/DHEA ratios were significantly increased in MDD/BPD patients as compared with the healthy comparison group.

CONCLUSIONS

Depressed patients with comorbid BPD display endocrine and immune alterations similar to those observed in cases of melancholic MDD without BPD. Elevated concentrations of serum cortisol, cortisol/DHEA ratios, and pro-inflammatory cytokines might indicate a state marker in these patients and might contribute to long-term metabolic alterations that have also been associated with MDD.

Major depression in patients with borderline personality disorder: a clinical investigation

OBJECTIVE

Borderline personality disorder (BPD) is characterized by a high frequency of comorbidity with major depressive disorder (MDD). This study aimed to compare the clinical characteristics of 2 groups of patients with MDD: those with concomitant BPD and those with other concomitant personality disorders.

METHODS

We assessed 119 outpatients, using a semistructured interview for demographic and clinical features, the Structured Clinical Interview for DSM-IV, Hamilton anxiety and depression scales, the Zung Self-Rating Depression Scale (ZSDS), the Social and Occupational Functioning Assessment Scale (SOFAS), the Sheehan Disability Scale, and the Revised Childhood Experiences Questionnaire. We performed a regression analysis, using the number of criteria for BPD as the dependent variable.

RESULTS

Severity of BPD was positively related to the ZSDS score, to self-mutilating behaviours, and to the occurrence of mood disorders in first-degree relatives; it was negatively related to the SOFAS score and age at onset of MDD.

CONCLUSIONS

Patients with comorbid MDD and BPD present differential characteristics that indicate a more serious and impairing condition with a stronger familial link with mood disorders than is shown by depression patients with other Axis II codiagnoses.

Associations in the course of personality disorders and Axis I disorders over time

In this study, the authors examined time-varying associations between schizotypal (STPD), borderline (BPD), avoidant (AVPD), or obsessive-compulsive (OCPD) personality disorders and co-occurring Axis I disorders in 544 adult participants from the Collaborative Longitudinal Personality Disorders Study. The authors tested predictions of specific longitudinal associations derived from a model of crosscutting psychobiological dimensions (L. J. Siever & K. L. Davis, 1991) with participants with the relevant Axis I disorders. The authors assessed participants at baseline and at 6-, 12-, and 24-month follow-up evaluations. BPD showed significant longitudinal associations with major depressive disorder and posttraumatic stress disorder. AVPD was significantly associated with anxiety disorders (specifically social phobia and obsessive-compulsive disorder). Two of the four personality disorders under examination (STPD and OCPD) showed little or no association with Axis I disorders.

Increased diurnal salivary cortisol in women with borderline personality disorder

Borderline personality disorder (BPD) is characterized by a pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image. In previous studies, we have used portable mini-computers to assess the severity of recurrent states of aversive emotional distress and dissociation during ambulatory conditions. Here, we used this approach for the assessment of the hypothalamic-pituitary-adrenal (HPA) axis in patients with BPD. We studied 23 unmedicated female patients with BPD and 24 matched healthy controls. Salivary cortisol was collected from all participants during ambulatory conditions in response to reminders provided by portable mini-computers on 3 consecutive days every 2 h for 14 h after awakening. In addition, cortisol in response to awakening was determined in four 15 min intervals on days 1 and 2. After the last collection of cortisol on the second day, 0.5 mg dexamethasone was administered in order to achieve cortisol suppression on day 3 (low-dose dexamethasone suppression test, DST). Patients with BPD displayed significantly higher salivary cortisol levels than healthy controls as demonstrated by higher total cortisol in response to awakening and higher total daily cortisol levels. There were significantly more non-suppressors of cortisol in the low-dose DST in the patient group when compared to the control group. The ambulatory assessment of saliva cortisol is a suitable approach to study basic parameters of the HPA-axis in patients with BPD. Increased adrenal activity and lowered feedback sensitivity of the HPA-axis may characterise BPD. Further studies have to reveal reasons of heightened adrenal activity in these patients.

Psychodynamic personality profile in first-episode severe mental disorders

OBJECTIVE

The aim of this study was to relate measures of psychoanalytically derived personality traits to descriptive diagnosis and psychopathology in severe mental disorders.

METHOD

Sixty-one consecutive first-episode patients with schizophrenia, bipolar disorder and severe major depression were interviewed. Personality traits were assessed with the Karolinska Psychodynamic Profile (KAPP) and compared with the DSM-IV diagnosis and symptom clusters derived from the BPRS.

RESULTS

There were no marked differences in personality traits between the three diagnostic groups, between schizophrenia and affective disorders or between psychotic and non-psychotic illness. However, personality traits had significant associations with symptoms, especially with the emotional retardation cluster.

CONCLUSION

Our findings do not support the hypothesis that severe mental disorders would differ from each other in terms of long-standing psychodynamic personality profiles. Certain dysfunctional personality traits may predict especially negative emotional symptoms and possibly also predispose a person to them.

No evidence of attentional deficits in stabilized bipolar youth relative to unipolar and control comparators

OBJECTIVE

The purpose of this study was to determine the presence or absence of attentional problems and prior diagnosis of ADHD in a cohort of stabilized bipolar I relative to unipolar and normal control.

METHOD

Indices of attention were obtained from bipolar (n = 44), unipolar (n = 30), and normal controls (n = 45). Measures included: Freedom from Distractibility (FD) Composite Index of the WISC III, Conners' Continuous Performance Test (CPT), Wisconsin Card Sorting Test (WCST), and a checklist measure of subjective cognitive/attentional problems (SIP-AV).

RESULTS

Bipolar (6.8%), unipolar (10%), and no control youth report a prior diagnosis of ADHD. No significant group or sex differences were observed on FD Composite Index, various CPT indices, or the WCST. Despite normative attentional function by objective testing, subjectively experienced cognitive problems in the clinical probands were reported.

CONCLUSIONS

This cohort of well-functioning bipolar youth diagnosed on average 3-4 years prior to assessment do not possess attentional deficits based on a variety of objective tests compared to unipolar or control youth, but self report subjective difficulties in attentional/problem solving ability. In contrast to other authors, we do not find that bipolar youth have high rates of comorbid ADHD.

Abuse and neglect in childhood: relationship to personality disorder diagnoses

BACKGROUND

Childhood history of abuse and neglect has been associated with personality disorders and has been observed in subjects with lifetime histories of suicidality and self-injury. Most of these findings have been generated from inpatient clinical samples.

METHODS

This study evaluated self-rated indices of sustained childhood abuse and neglect in an outpatient sample of well-characterized personality disorder subjects (n=182) to determine the relative associations of childhood trauma indices to specific personality disorder diagnoses or clusters and to lifetime history of suicide attempts or gestures. Subjects met criteria for ~2.5 Axis II diagnoses and 24% reported past suicide attempts. The Childhood Trauma Questionnaire was administered to assess five dimensions of childhood trauma exposure (emotional, physical, and sexual abuse, and emotional and physical neglect). Logistic regression was employed to evaluate salient predictors among the trauma measures for each cluster, personality disorder, and history of attempted suicide and self-harm. All analyses controlled for gender distribution.

RESULTS

Seventy-eight percent of subjects met dichotomous criteria for some form of childhood trauma; a majority reported emotional abuse and neglect. The dichotomized criterion for global trauma severity was predictive of cluster B, borderline, and antisocial personality disorder diagnoses. Trauma scores were positively associated with cluster A, negatively with cluster C, but were not significantly associated with cluster B diagnoses. Among the specific diagnoses comprising cluster A, paranoid disorder alone was predicted by sexual, physical, and emotional abuse. Within cluster B, only antisocial personality disorder showed significant associations with trauma scores, with specific prediction by sexual and physical abuse. For borderline personality disorder, there were gender interactions for individual predictors, with emotional abuse being the only significant trauma predictor, and only in men. History of suicide gestures was associated with emotional abuse in the entire sample and in women only; self-mutilatory behavior was associated with emotional abuse in men.

CONCLUSION

These results suggest that childhood emotional abuse and neglect are broadly represented among personality disorders, and associated with indices of clinical severity among patients with borderline personality disorder. Childhood sexual and physical abuse are highlighted as predictors of both paranoid and antisocial personality disorders. These results help qualify prior observations of the association of childhood sexual abuse with borderline personality disorder.

The relation between depressive symptoms and borderline personality disorder features over time in dysthymic disorder

Dysthymic Disorder (DD) and Borderline Personality Disorder (BPD) frequently co-occur. To understand this association better, we tested four competing models of the relationship between depressive and BPD symptoms over time in DD: (a) no association between depression and BPD over time; (b) contemporaneous direct effects in which BPD features and depressive symptoms influence one another over a relatively short time period; (c) lagged direct effects in which one condition influences the other condition over a longer period; and (d) a fixed common factor underlies both depression and BPD, along with influences that are unique to each condition. We assessed 84 outpatients with DD three times over 5 years using semistructured interviews. Data were analyzed using structural equation modeling techniques. The fixed common factor model was the best fitting of the models, providing an excellent fit to the data. These results suggest that depressive symptoms and BPD features in DD arise from partially overlapping processes.

Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences

OBJECTIVES

many studies have reported a high degree of comorbidity between mood disorders, among which are bipolar disorders, and borderline personality disorder and some studies have suggested that these disorders are co-transmitted in families. However, few studies have compared personality traits between these disorders to determine whether there is a dimensional overlap between the two diagnoses. The aim of this study was to compare impulsivity, affective lability and intensity in patients with borderline personality and bipolar II disorder and in subjects with neither of these diagnoses.

METHODS

patients with borderline personality but without bipolar disorder (n=29), patients with bipolar II disorder without borderline personality but with other personality disorders (n=14), patients with both borderline personality and bipolar II disorder (n=12), and patients with neither borderline personality nor bipolar disorder but other personality disorders (OPD; n=93) were assessed using the Affective Lability Scale (ALS), the Affect Intensity Measure (AIM), the Buss-Durkee Hostility Inventory (BDHI) and the Barratt Impulsiveness Scale (BIS-7B).

RESULTS

borderline personality patients had significantly higher ALS total scores (P<0.05) and bipolar II patients tended to have higher ALS scores than patients with OPD (P<0.06). On one of the ALS subscales, the borderline patients displayed significant higher affective lability between euthymia and anger (P<0.002), whereas patients with bipolar II disorder displayed affective lability between euthymia and depression (P<0.04), or elation (P<0.01) or between depression and elation (P<0.01). A significant interaction between borderline personality and bipolar II disorder was observed for lability between anxiety and depression (P<0.01) with the ALS. High scores for impulsiveness (BISTOT, P<0.001) and hostility (BDHI, P<0.05) were obtained for borderline personality patients only and no significant interactions between diagnoses were observed. Only borderline personality patients tended to have higher affective intensity (AIM, P<0.07).

CONCLUSIONS

borderline personality disorder and bipolar II disorder appear to involve affective lability, which may account for the efficacy of mood stabilizers treatments in both disorders. However, our results suggest that borderline personality disorder cannot be viewed as an attenuated group of affective disorders.

Psychopharmacology of personality disorders: review and emerging issues

Progress with the development of models and general principles of psychopharmacologic management of personality disordered patients is reviewed. Recent research using mood stabilizers and novel antipsychotics are discussed. The effects of these medications on impulsive aggressiveness are supported and the effects are evident early and are independent of the effects on mood, including depression. Research is needed with other personality disorders beyond just borderline personality disorder. Future research must develop measurable outcomes and delineate the causal and temporal relationships between the psychopathologic features of personality disorders.

Modeling the relationship between affective lability, impulsivity, and suicidal behavior in patients with borderline personality disorder

This article reviews the concept of affective lability and suggests that new models are needed to characterize the relationship between affective states such as affective lability, impulsivity, and suicidal behavior. The association of affective lability, impulsivity, and suicidal behavior is most relevant to understanding the risk of suicide in individuals with borderline personality disorder. The relationship between affective lability and suicide might be explained as 1) a form of bipolarity, 2) a form of impulse dyscontrol, 3) a quantitative disorder of affect, or 4) an environmental reactivity. Our opinion of the relevant literature suggests that a quantitative disorder of affect accompanied by the inability to control these affects are the essential components leading to the risk of suicidal behavior. Characterizing the dyscontrol and high intensity of affect leads to a reconceptualization of depression in patients with borderline personality disorder and to a re-examination of the causal chain of events leading to suicidal behavior. The implications for clinical practice resulting from the proposed model are discussed.