The TRH-stimulation test in DSM-III personality disorder

Targeting the Endocannabinoid System in Borderline Personality Disorder: Corticolimbic and Hypothalamic Perspectives

Borderline Personality Disorder (BPD) is a chronic debilitating psychiatric disorder characterized mainly by emotional instability, chaotic interpersonal relationships, cognitive disturbance (e.g., dissociation and suicidal thoughts) and maladaptive behaviors. BPD has a high rate of comorbidity with other mental disorders and a high burden on society. In this review, we focused on two compromised brain regions in BPD - the hypothalamus and the corticolimbic system, emphasizing the involvement and potential contribution of the endocannabinoid system (ECS) to improvement in symptoms and coping. The hypothalamus-regulated endocrine axes (hypothalamic pituitary - gonadal, thyroid & adrenal) have been found to be dysregulated in BPD. There is also substantial evidence for limbic system structural and functional changes in BPD, especially in the amygdala and hippocampus, including cortical regions within the corticolimbic system. Extensive expression of CB1 and CB2 receptors of the ECS has been found in limbic regions and the hypothalamus. This opens new windows of opportunity for treatment with cannabinoids such as cannabidiol (CBD) as no other pharmacological treatment has shown long-lasting improvement in the BPD population to date. This review aims to show the potential role of the ECS in BPD patients through their most affected brain regions, the hypothalamus and the corticolimbic system. The literature reviewed does not allow for general indications of treatment with CBD in BPD. However, there is enough knowledge to indicate a treatment ratio of a high level of CBD to a low level of THC. A randomized controlled trial investigating the efficacy of cannabinoid based treatments in BPD is warranted.

Relationship between chronobiological thyrotropin and prolactin responses to protirelin (TRH) and suicidal behavior in depressed patients

BACKGROUND

So far, investigations of the relationships between suicidality and the activity of the thyrotropic and lactotropic axes are scarce and have yielded conflicting results.

METHODS

We studied the thyrotropin (TSH) and prolactin (PRL) responses to 0800h and 2300h protirelin (TRH) stimulation tests, carried out on the same day, in 122 euthyroid DSM-5 major depressed inpatients with suicidal behavior disorder (SBD) (either current [n=71], or in early remission [n=51]); and 50 healthy hospitalized controls.

RESULTS

Baseline TSH and PRL measurements did not differ across the 3 groups. In SBDs in early remission, the TSH and PRL responses to TRH tests (expressed as the maximum increment above baseline value after TRH [Δ]) were indistinguishable from controls. Current SBDs showed (1) lower 2300h-ΔTSH and lower ΔΔTSH values (differences between 2300h-ΔTSH and 0800h-ΔTSH) than controls and SBDs in early remission; and (2) lower baseline free thyroxine (FT_4B) levels than controls. In the current SBD group, ΔΔPRL values (differences between 2300h-ΔPRL and 0800h-ΔPRL) were correlated negatively with lethality. Moreover, in current SBDs (1) violent suicide attempters (n=15) showed lower FT_4B levels, lower TSH-TRH responses (both at 0800h and 2300h), and lower ΔΔTSH and ΔΔPRL values than controls, while (2) non-violent suicide attempters (n=56) showed lower ΔΔTSH values than controls and higher TSH-TRH responses (both at 0800h and 2300h) than violent suicide attempters.

CONCLUSIONS

Our results suggest that central TRH secretion is not altered in depressed patients with SBD in early remission. The findings that current SBDs exhibit both decreased FT_4B levels and decreased evening TSH responses (and consequently, decreased ΔΔTSH values) support the hypothesis that hypothalamic TRH drive is reduced-leading to an impaired TSH resynthesis in the pituitary during the day after the morning TRH challenge. In violent suicide attempters, the marked abnormalities of TRH test responses might indicate a greatest reduction in hypothalamic TRH drive. These results further strengthen the possibility that a deficit in central TRH function may play a key role in the pathogenesis of suicidal behavior.

Prolactin and thyroid hormone levels are associated with suicide attempts in psychiatric patients

The aim of this study is to evaluate biological factors associated with recent suicidal attempts in a naturalistic sample. A total of 439 patients suffering from major depression disorder (MDD), bipolar disorder (BD) and psychotic disorders (schizophrenia, schizoaffective disorder and psychosis not otherwise specified), who were consecutively assessed in the Emergency Department of an Italian Hospital (January 2008-December 2009), were included. In the whole sample, suicide attempters and non-attempters differed with regard to free triiodothyronine (FT3) and prolactin values only. A univariate general linear model indicated significant effects of sex (F(1;379)=9.29; P=0.002), suicidal status (F(1;379)=4.49; P=0.04) and the interaction between sex and suicidal status (F(1;379)=5.17; P=0.02) on prolactin levels. A multinomial logistic regression model indicated that suicidal attempters were 2.27 times (odds ratio (OR)=0.44; 95% confidence interval (95%CI): 0.23/0.82; P=0.01) less likely to have higher FT3 values than non-attempters; while prolactin values failed to reach statistical significance (OR=0.99; 95%CI: 0.98/1.00; P=0.051). Both prolactin and thyroid hormones may be involved in a complex compensatory mechanism to correct reduced central serotonin activity. Further studies may help in understanding how these findings can be used by clinicians in assessing suicide risk.

Thyroid axis activity and suicidal behavior in depressed patients

The aim of this study was to investigate the relationship between suicidal behavior and hypothalamic-pituitary thyroid (HPT) axis activity in depressed patients. The serum levels of thyrotropin (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) were evaluated before and after 0800 and 2300 h thyrotropin-releasing hormone (TRH) challenges, on the same day, in 95 medication-free DSM-IV euthyroid major depressed inpatients and 44 healthy hospitalized controls. Compared to controls: (1) patients with a positive suicide history (PSH; n=53) showed lower basal FT4 (at 0800 h: p<0.005; at 2300 h: p<0.03), but normal FT3 levels, while patients with a negative suicide history (NSH; n=42) showed normal FT4 and FT3 levels; (2) TSH responses to TRH (DeltaTSH) were blunted in NSHs (at 0800 h: p<0.03; at 2300 h: p<0.00001), but not in PSHs; (3) both NSHs and PSHs showed lower DeltaDeltaTSH values (differences between 2300 h-DeltaTSH and 0800 h-DeltaTSH) (p<0.000001 and p<0.003, respectively). Compared to NSHs, basal FT4 levels were reduced in PSHs (at 0800 h: p<0.002; at 2300h: p<0.006). HPT parameters were not significantly different between recent suicide attempters (n=32) and past suicide attempters (n=21). However, compared to controls, recent suicide attempters showed lower 2300 h-DeltaTSH (p<0.04) and DeltaDeltaTSH (p<0.002) values, and lower basal FT4 values (at 0800 h: p<0.006; at 2300 h: p<0.02). Our results, obtained in a large sample of depressed inpatients, indicate that various degrees of HPT axis dysregulation are associated with the history of suicide.

Is the biological nature of depressive symptoms in borderline patients without concomitant Axis I pathology idiosyncratic? Sleep EEG comparison with recurrent brief, major depression and control subjects

The relationship between borderline personality disorder (BPD) and the affective disorders is controversial, and we have previously compared BPD and major depression (MD) with endocrinological measures and sleep electroencephalography (S-EEG). We have also compared BPD, MD and recurrent brief depression (RBD) using endocrine tests. We have proposed that depressive symptoms in BPD might have a biological substrate that is distinct from those in depressive illness without comorbid BPD. BPD has been proposed to overlap with RBD, which has been found to share perturbed biological substrates with MD, but we have not found the same biological pattern in BPD. When endocrinological data in BPD, MD and RBD were compared, we did not find evidence of biological linkage between BPD and RBD. To clarify the biological nature of depressive symptoms in BPD, we examined S-EEG characteristics in BPD, RBD, MD and controls. Among 20 BPD patients, 12 were also diagnosed as having clinical RBD. BPD patients showed differences in sleep continuity and especially in sleep architecture compared with RBD, MD and controls. BPD with or without clinical RBD did not show significant differences in any parameter. BPD with or without clinical RBD had less slow sleep activity not only than MD but also than non-borderline RBD patients. We propose that although BPD patients can have concomitant MD, they often exhibit a specific BPD-associated affective syndrome that is different from both MD and non-borderline RBD in the quality and duration of symptoms and the biological substrate.

Effects of carbamazepine on dexamethasone suppression and sleep electroencephalography in borderline personality disorder

The pathophysiology of borderline personality disorder (BPD) remains obscure, but there is mounting evidence of brain dysfunction without focal abnormality. The dexamethasone suppression test (DST) and sleep electroencephalography (sleep EEG) have been studied in BPD, but the findings seem to be related to a concomitant axis I diagnosis of major depression (MD) rather than to BPD itself. There is no effective treatment for BPD. Carbamazepine (CBZ) has shown contradictory results and in a previous study, our results were negative. In this study, we investigated the effects of CBZ versus placebo on the DST and sleep EEG in a sample of 20 BPD patients without concomitant MD. CBZ given at doses that are therapeutic for epilepsy and affective disorders may have an effect on the DST and sleep EEG in BPD. CBZ significantly increased the postdexamethasone plasma cortisol values. This did not parallel MD or an increase in the Hamilton depression rating scores. CBZ also increased slow wave sleep (SWS). The mechanisms by which CBZ increased postdexamethasone plasma cortisol levels and SWS in BPD are discussed.

Sleep-EEG in borderline patients without concomitant major depression: a comparison with major depressives and normal control subjects

The link between borderline personality disorder (BPD) and the affective disorders remains controversial. The aim of this study was to examine the relationships between BPD and major depression (MD) from the perspective of sleep parameters and to contribute to the characterisation of the sleep-EEG in BPD. We compared 20 off-medication BPD in-patients without co-existing MD with 20 sex- and age-matched MD patients without BPD and 20 sex- and age-matched control subjects. BPD patients had a greater prevalence of drug or alcohol abuse and suicide attempts than MD patients. MD patients had higher scores on the Hamilton Depression Rating Scale (HDRS). Both BPD and MD patients had less total sleep time, more prolonged sleep onset latency, and a greater percentage of wakefulness than control subjects. BPD patients and control subjects had more stage 2 sleep than MD patients. BPD patients had a longer duration of rapid eye movement (REM) sleep, and less stage 3, stage 4 and slow wave sleep than MD patients and control subjects. REM latency did not differentiate the three groups. BPD and MD patients shared sleep-continuity characteristics, but sleep architecture differentiated the two groups. BPD patients with a past history of MD had more wakefulness and less slow wave sleep than BPD patients without a history of MD; other sleep parameters, age, sex and HDRS scores were not statistically different in the two BPD subgroups. Although BPD and MD may coexist, the present study offers more arguments favouring the concept that they are not biologically linked and that BPD patients with depressive symptoms often experience an affective syndrome different from that in MD patients without BPD, in terms of quality and duration of symptoms and of the biological substrate.

Effect of present pain and mood on the memory of past postoperative pain in women treated surgically for breast cancer

In our recent retrospective study on breast cancer patients, the intensity of the past postoperative pain was a primary factor in predisposing the development of chronic post-treatment pain. The present prospective study was designed to find out if the remembered intensity of postoperative pain (RIPP) after breast surgery was influenced by the development of chronic pain and if the RIPP had any correlation with the development of depression or anxiety. The patient's estimation of the severity of the RIPP was determined three times in the year after surgery. The state anxiety and depression and the presence of pain in the ipsilateral arm were assessed before the operation, and 1, 6 and 12 mos after surgery. Ninety-three consecutive female patients with breast cancer who were enrolled for surgical treatment were recruited to the study during 1993-1994. The patients were treated with modified radical mastectomy with axillary clearance (n = 53) or breast resection with axillary clearance (n = 40). The patients' records were checked for the consumption of analgesics within the first 48 h after surgery. The patients were analysed in three groups according to the presence or absence of preoperative or chronic post-treatment pain. There was a significant correlation between the RIPP and the consumption of both opioids and NSAIDs on the ward. The women who had chronic pain remembered having had more severe postoperative pain compared with those women who had no chronic pain. The RIPP increased with time in the chronic pain patients whereas it decreased in the patients who had no chronic pain. In all patients the preoperatively measured state anxiety and depression scores were higher than in healthy Finnish women. One year after surgery anxiety and depression had returned to normal levels except in the patients who had chronic pain. Their depression remained at a higher level during the first year after surgery. The results suggest that the amount of postoperative pain may play a role in the development of chronic pain. However, the development of chronic pain is connected to a tendency to overestimate previous pain and to higher levels of depression.

Pain and other symptoms during the first year after radical and conservative surgery for breast cancer

This study assessed pain, neurological symptoms, oedema of the ipsilateral arm, anxiety and depression occurring in women treated surgically for breast cancer, the impact of these symptoms on daily life and how they evolved during the 1 year follow-up. Ninety-three consecutive patients with non-metastasised breast cancer who were treated during 1993-94 were examined before surgery and after 1, 6 and 12 months. They were asked about pain, neurological symptoms and oedema in the breast scar region and/or ipsilateral arm. Sensory testing was performed, and gripping force and the circumference of the arm were measured. Anxiety and depression were evaluated. One year after surgery, 80% of the women had treatment-related symptoms in the breast scar region and virtually all patients had symptoms in the ipsilateral arm. The incidence of chronic post-treatment pain was higher after conservative surgery than after radical surgery (breast area: 33% vs 17%, NS; ipsilateral arm: 23% vs 13%, NS). Numbness occurred in 75% and oedema of the ipsilateral arm in over 30% of the patients after both radical and conservative surgery. Phantom sensations in the breast were reported by 25% of the patients. No difference in psychic morbidity was detected after the two types of surgery. Both the anxiety and depression scores were highest before surgery, decreasing with time, and were significantly correlated with preoperative stressful events.

TRH stimulation and dexamethasone suppression in borderline personality disorder

The link between borderline personality disorder (BPD) and affective disorders is controversial. The dexamethasone suppression test (DST) and the thyrotropin-releasing hormone (TRH) stimulation test, which are useful in the study of affective illness, might help to elucidate this possible link. This report assessed these endocrine tests in a sample of 20 borderline patients without a concomitant diagnosis of major depression (but showing depressive symptoms) in comparison to a group of sex- and age-matched patients with major depressive disorder (MDD) without BPD. Only 5 of our BPD patients were DST nonsuppressors compared to 13 MDD patients at a threshold of 50 micrograms/L. With a threshold of delta max TSH < 5 microU/mL following TRH, 1 BPD patient showed a blunted TSH response compared to 9 MDD patients. BPD patients displayed significantly less perturbed tests. These results show no evidence of an endocrine biological link between BPD and the MDD. The depressive symptoms observed in BPD patients might not have the same biological substrates as those found in patients with MDD.