Presence and Overlap of Bipolar Symptoms and Borderline Features during Major Depressive Episodes

Functional magnetic resonance imaging studies in bipolar disorder in resting state: A coordinates-based meta-analysis

Exploring changes in the intrinsic activity of the brain in people with bipolar disorder (BD) is necessary. However, the findings have not yet led to consistent conclusions. In this regard, this paper aims to extract more obvious differential brain areas and neuroimaging markers, for the purpose of providing assistance for early clinical diagnosis and subsequent treatment. We conducted a meta-analysis of whole-brain resting-state functional magnetic resonance imaging (rs-fMRI) studies using seed-based d-mapping software that examined differences in amplitude of low-frequency fluctuations (ALFF), fractional amplitude of low-frequency fluctuations (fALFF), and regional homogeneity (ReHo) between patients with BD and healthy controls (HCs). Seed-based d-Mapping (formerly Signed Differential Mapping) with Permutation of Subject Images, or SDM-PSI, is a statistical technique for meta-analyzing studies of differences in brain activity or structure. A total of 16 articles involving 1112 individuals were included in this study for meta-analysis. This paper confidently analyzes the correlation between the clinical scales HAMD, HAMA, and YMRS, and the area of difference. We found significant changes that increased activation in the anterior connective and left lens nucleus, the nucleus of the shell, and BA 48 in BD patients compared with HC (P < 0.05, uncorrected), as well as a significant correlation between HAMD and the left superior frontal gyrus (after FWE correction P < 0.05). Therefore, basal ganglia and frontal cortex may have important significance in the pathogenesis and pathological basis of BD, making it an important issue to be attached importance to.

How changes in depression severity and borderline personality disorder intensity are linked - a cohort study of depressed patients with and without borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is often complicated by comorbid major depressive episodes (MDEs), which can occur as part of major depressive disorder (MDD) or bipolar disorder (BD). Such comorbidity is related to worse outcomes in both disorders. Subsyndromal features of BPD are also common in depression. However, studies of simultaneous changes in BPD and depression severities are scarce, and their interactions are poorly understood.

AIMS

Studying the associations between changes in BPD and depression symptoms over the course of an MDE.

METHODS

In a 6-month naturalistic cohort study of MDE/BPD, MDE/MDD, and MDE/BD patients (N = 95), we measured change in BPD features between baseline and six months with the Borderline Personality Disorder Severity Index (BPDSI), an interviewer-rated instrument quantifying recent temporal frequency of BPD symptoms. We examined changes in BPD severity and their correlation with depression severity and other clinical measures and compared these across patient groups.

RESULTS

There were significant reductions in BPD severity, both in number of positive BPD criteria (-0.35, sd 1.38, p = 0.01672) and in BPDSI scores (-4.23, SD 6.74, p < 0.001), reflecting mainly a reduction in temporal frequency of symptoms. These were similar in all diagnostic groups. In multivariate regression models, changes in depression severity independently associated with changes in symptoms in the BDSI. This relationship was strongest in MDE/BPD patients but was not found in MDD patients without BPD.

CONCLUSIONS

In the six-month follow-up, BPD features in MDE patients alleviated mainly by decreasing temporal symptom frequency and intensity. In BPD patients with comorbid MDE, changes in both conditions are strongly correlated.

Affect dimensions and variability during major depressive episodes: Ecological momentary assessment of unipolar, bipolar, and borderline patients and healthy controls

Differentiating major depressive episodes (MDEs) of major depressive disorder (MDD), bipolar disorder (MDE/BD) and the MDEs comorbid with borderline personality disorder (MDE/BPD) is crucial for appropriate treatment, and knowledge of phenomenological differences may aid this. However, studies comparing affect experiences of these three patient groups and healthy subjects are scarce. In our study, participants (N = 114), including patients with MDD (n = 34), MDE/BD (n = 27), and MDE/BPD (n = 24), and healthy controls (HC, n = 29) responded to ecological momentary assessment (EMA) with ten circumplex model affect items ten times daily for seven days (7709 recordings). Explorative factor analysis resulted in two affect dimensions. The positive dimension included active, excited, cheerful (high arousal), and content (low arousal) affects, and the negative dimension irritated, angry, and nervous (high arousal) affects. Relative to HC, patients reported 3.5-fold negative affects (mean MDD 1.36 (SD 0.92), MDE/BD 1.43 (0.76), MDE/BPD 1.81 (0.95) vs. HC 0.44 (0.49) (p < 0.01)) but 0.5-fold positive affects (2.01 (0.90), 1.95 (0.89), 2.24 (1.03), vs. 3.2 (0.95), respectively (p < 0.01)). We used multilevel modelling. Negative-affect within-individual stability was lowest in MDE/BPD and highest in MDD. Negative affect predicted concurrent positive affect more in MDE/BPD than in MDD. Moderate size of subcohorts and no inpatients were limitations. Despite apparently similar MDEs, affective experiences may differ between BPD, BD, and MDD patients. Clinical subgroups of patients with depression may vary in affective instability and concurrent presence of negative and positive affects during depression.

Mental Illness Diagnoses May Not Cause All Mental Symptoms: A Simulation Study for Major Depressive Episodes, Dysthymic Disorder, and Manic Episodes

Objectives This study aims to understand the statistical significance of the associations between diagnoses and symptoms based on simulations that have been used to understand the interpretability of mental illness diagnoses. Methods The symptoms for the diagnosis of major depressive episodes, dysthymic disorder, and manic episodes were extracted from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR, American Psychiatric Association, Philadelphia, Pennsylvania). Without real-world symptom data, we simulated populations using various combinations of symptom prevalence and correlations. Assuming symptoms occurred with similar prevalence and correlations, for each combination of symptom prevalence (0.05, 0.1, 0.3, 0.5, and 0.7) and correlation (0, 0.1, 0.4, 0.7, and 0.9), 100 cohorts with 10,000 individuals were randomly created. Diagnoses were made according to the DSM-IV-TR criteria. The associations between the diagnoses and their input symptoms were quantified with odds ratios and correlation coefficients. P-values from 100 cohorts for each combination of symptom prevalence and correlation were summarized. Results Three mental illness diagnoses were not significantly correlated with their own symptoms in all simulations, particularly when symptoms were not correlated, except for the symptom in the major criteria of major depressive episodes or dysthymic disorder. The symptoms for the diagnosis of major depressive episodes and dysthymic disorder were significantly correlated with these two diagnoses in some simulations, assuming 0.1, 0.4, 0.7, or 0.9 symptom correlations, except for one symptom. The overlap in the input symptoms for the diagnosis of major depressive episodes and dysthymic disorder also leads to significant correlations between these two diagnoses, assuming 0.1, 0.4, 0.7, and 0.9 correlations between input symptoms. Manic episodes are not significantly associated with the input symptoms of major depressive episodes and dysthymic disorder. Conclusion There are challenges to establish the causation between psychiatric symptoms and mental illness diagnoses. There is insufficient prevalence and incidence data to show all psychiatric symptoms exist or can be observed in patients. The diagnostic accuracy of symptoms to detect a disease cause is far from perfect. Assuming the symptoms of three mood disorders may present in patients, three diagnoses are not significantly associated with all psychiatric symptoms used to diagnose them. The diagnostic criteria of the three diagnoses have not been designed to guarantee significant associations between symptoms and diagnoses. Because statistical associations are important for making causal inferences, there may be a lack of causation between diagnoses and symptoms. Previous research has identified factors that lead to insignificant associations between diagnoses and symptoms, including biases due to data processing and a lack of epidemiological evidence to support the design of mental illness diagnostic criteria.

Borderline personality disorder and depression severity predict suicidal outcomes: A six-month prospective cohort study of depression, bipolar depression, and borderline personality disorder

BACKGROUND

Suicide risk is high in patients with major depressive disorder (MDD), bipolar disorder (BD) and borderline personality disorder (BPD). Whether risk levels of and risk factors for suicidal ideation (SI) and suicide attempts (SA) are similar or different in these disorders remains unclear, as few directly comparative studies exist. The relationship of short-term changes in depression severity and SI is underinvestigated, and might differ across groups, for example, between BPD and non-BPD patients.

METHODS

We followed, for 6 months, a cohort of treatment-seeking, major depressive episode (MDE) patients in psychiatric care (original n = 124), stratified into MDE/MDD, MDE/BD and MDE/BPD subcohorts. We examined risks of suicide-related outcomes and their risk factors prospectively. We examined the covariation of SI and depression over time with biweekly online modified Patient Health Questionnaire 9 surveys and analysed this relationship through multi-level modelling.

RESULTS

Risk of SA in BPD (22.2%) was higher than non-BPD (4.23%) patients. In regression models, BPD severity was correlated with risk of SA and clinically significant SI. During follow-up, mean depression severity and changes in depression symptoms were associated with SI risk regardless of diagnosis.

CONCLUSIONS

Concurrent BPD in depression seems predictive for high risk of SA. Severity of BPD features is relevant for assessing risk of SA and SI in MDE. Changes in depressive symptoms indicate concurrent changes in risk of SI. BPD status at intake can index risk for future SA, whereas depressive symptoms appear a useful continuously monitored risk index.

Bipolar disorder predicted shorter and borderline personality disorder symptoms longer time to remission - A prospective cohort study of major depressive patients

BACKGROUND

Major depressive episodes (MDEs) of major depressive (MDD) or bipolar disorders (BD) are frequently complicated by features of borderline personality disorder (BPD). Mixed features are a hallmark of BD and affective lability of BPD, and both may markedly influence illness course. However, direct comparisons of outcome of depression in MDD, BD, and BPD are scarce.

METHODS

In a cohort study based on stratified sampling, we diagnosed psychiatric MDE patients with SCID-I/P and SCID-II interviews and examined mixed symptoms using the Mix-MDE scale and borderline symptoms using the Borderline Personality Disorder Severity Index. During a six-month prospective follow-up, the MDE patients with MDD (n = 39), BD (n = 33), or BPD (n = 23) completed biweekly online assessments. Using life chart methodology, we divided the follow-up period into qualitatively different mood state periods. We investigated durations of mood episodes, times to first full symptomatic remission, and their predictors.

RESULTS

Remission rates were similar in MDD, MDE/BD, and MDE/BPD patients. MDE/BD patients experienced more numerous and shorter distinct mood state periods during follow-up than the others. MDE/BD was associated with shorter (HR = 2.44, 95 % CI = 1.27-4.67) and dimensionally assessed BPD severity with longer time to first remission (HR = 0.95, 95 % CI = 0.91-1.00).

LIMITATIONS

Moderate sample size and follow-up duration.

CONCLUSIONS

Course of illness over six months differs between the three depressive groups. Bipolar depressive patients have the most alternating course and the shortest time to first period of remission. Dimensionally assessed severity of BPD may predict longer time to remission from depression.

Borderline Personality Pathology in Major Depressive Disorder, Bipolar I and II Disorder, and Its Relationship With Childhood Trauma

OBJECTIVE

Mood disorder and borderline personality pathology (BPP) are frequently comorbid and relate to childhood trauma. We investigated the relationship between childhood trauma and BPP features in mood disorder patients versus controls.

METHODS

A total of 488 mood disorder patients, particularly major depressive disorder (MDD), bipolar I disorder (BD I), and bipolar II disorder (BD II), and 734 controls were included. We examined between-group BPP-related differences and correlated between BPP and childhood trauma using the Childhood Trauma Questionnaire-Short Form (CTQ) and the Personality Assessment Inventory-Borderline Features Scale.

RESULTS

BD II patients showed significantly higher BPP. Emotional abuse and neglect were prominently associated with BPP, while affective instability and negative relationships exhibited a stronger association with childhood trauma. We also found a positive relationship between childhood trauma and BPP in MDD, BD I, and BD II patients.

CONCLUSION

The findings of the present study imply that BPP features are more likely to be found in patients with BD II than BD I or MDD. Mood disorder patients with severe childhood trauma may have higher BPP features. Thus, further study of the relationship between childhood trauma and BPP features could improve the therapeutic approaches and help understand patients with mood disorders.

Attenuated niacin skin flushing response in children and adolescents with mental disorders: A transdiagnostic early warning marker

Mental disorders are the leading cause of disability in children and adolescents worldwide, but among the difficulties that pediatric mental health faces is a lack of objective biomarkers used for early identification or diagnosis. Studies to date indicate that niacin skin flushing response (NSFR) could be a biomarker for adult patients with schizophrenia and affective disorders. However, there are limited data on NSFR in pediatric patients with mental disorders. This study provides the first evidence of NSFR as a potential transdiagnostic marker in pediatric patients with schizophrenia (SZ), bipolar disorder (BD), depressive disorder (DD) and autism spectrum disorder (ASD). We conducted 10-min niacin skin flush tests on 227 pediatric participants, including 59 SZ patients, 23 BD patients, 57 DD patients, 40 ASD patients and 48 healthy controls (HCs). Group, time and the concentrations of aqueous methyl nicotinate had significant effects on the flush scores. Pediatric patients with BD, DD, and SZ clustered together, while ASD patients appeared to be more similar with HCs. SZ, BD and DD groups had lower flush scores than HCs, while ASD group had higher scores than BD and DD groups. These findings suggested NSFR was blunted in pediatric SZ, BD and DD and was distinct in ASD from the other disease groups. Our data demonstrate NSFR could be a transdiagnostic marker for pediatric SZ, BD and DD, which would help to identify a subgroup of patients sharing dysfunctions of membrane phospholipids. Besides, NSFR might have potential for early identification of affective disorders from ASD.

Understanding the development of bipolar disorder and borderline personality disorder in young people: a meta-review of systematic reviews

BACKGROUND

There is ongoing debate on the nosological position of bipolar disorder (BD) and borderline personality disorder (BPD). Identifying the unique and shared risks, developmental pathways, and symptoms in emerging BD and BPD could help the field refine aetiological hypotheses and improve the prediction of the onset of these disorders. This study aimed to: (a) systematically synthesise the available evidence from systematic reviews (SRs) and meta-analyses (MAs) concerning environmental, psychosocial, biological, and clinical factors leading to the emergence of BD and BPD; (b) identify the main differences and common features between the two disorders to characterise their complex interplay and, (c) highlight remaining evidence gaps.

METHODS

Data sources were; PubMed, PsychINFO, Embase, Cochrane, CINAHL, Medline, ISI Web of Science. Overlap of included SRs/MAs was assessed using the corrected covered area process. The methodological quality of each included SR and MA was assessed using the AMSTAR.

RESULTS

22 SRs and MAs involving 249 prospective studies met eligibility criteria. Results demonstrated that family history of psychopathology, affective instability, attention deficit hyperactivity disorder, anxiety disorders, depression, sleep disturbances, substance abuse, psychotic symptoms, suicidality, childhood adversity and temperament were common predisposing factors across both disorders. There are also distinct factors specific to emerging BD or BPD.

CONCLUSIONS

Prospective studies are required to increase our understanding of the development of BD and BPD onset and their complex interplay by concurrently examining multiple measures in BD and BPD at-risk populations.

Reduced visual contrast suppression during major depressive episodes

BACKGROUND

Previous studies have suggested that processing of visual contrast information could be altered in major depressive disorder. To clarify the changes at different levels of the visual hierarchy, we behaviourally measured contrast perception in 2 centre-surround conditions, assessing retinal and cortical processing.

METHODS

As part of a prospective cohort study, our sample consisted of controls (n = 29; 21 female) and patients with unipolar depression, bipolar disorder and borderline personality disorder who had baseline major depressive episodes (n = 111; 74 female). In a brightness induction test that assessed retinal processing, participants compared the perceived luminance of uniform patches (presented on a computer screen) as the luminance of the backgrounds was varied. In a contrast suppression test that assessed cortical processing, participants compared the perceived contrast of gratings, which were presented with collinearly or orthogonally oriented backgrounds.

RESULTS

Brightness induction was similar for patients with major depressive episodes and controls (p = 0.60, d = 0.115, Bayes factor = 3.9), but contrast suppression was significantly lower for patients than for controls (p < 0.006, d = 0.663, Bayes factor = 35.2). We observed no statistically significant associations between contrast suppression and age, sex, or medication or diagnostic subgroup. At follow-up (n = 74), we observed some normalization of contrast perception.

LIMITATIONS

We assessed contrast perception using behavioural tests instead of electrophysiology.

CONCLUSION

The reduced contrast suppression we observed may have been caused by decreased retinal feedforward or cortical feedback signals. Because we observed intact brightness induction, our results suggest normal retinal but altered cortical processing of visual contrast during a major depressive episode. This alteration is likely to be present in multiple types of depression and to partially normalize upon remission.

Prevalence of Comorbid Personality Disorder in Psychotic and Non-psychotic Disorders

Introduction: The burden of personality disorders (PDs) in China is large and the focus on mental health services is increasing. However, there is a lack of sufficient evidence regarding the prevalence of comorbid PD in psychotic and non-psychotic disorders, and whether PDs have different distributions. We aimed to investigate the PD comorbidity distribution pattern between psychotic and non-psychotic disorders using a clinical population-based study. Materials and Methods: We conducted a cross-sectional study of 1,497 patients in Shanghai. PDs were screened using the Personality Diagnostic Questionnaire Fourth Edition Plus (PDQ-4+). All patients were interviewed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) Axis II (SCID-II). We compared the differences in PD comorbidities classified as the 10 types of PDs in the DSM-IV, in 531 patients with psychosis and 966 patients with non-psychotic disorders. Results: More than one-third (37%) of patients with psychotic disorders met the criteria of at least one PD. Approximately half (46%) of patients with non-psychotic disorders met the criteria of at least one PD. Patients with non-psychotic disorders were more likely to meet the criteria of borderline (χ² = 20.154, p < 0.001) and obsessive-compulsive PD (χ² = 21.164, p < 0.001) diagnoses compared to those with psychotic disorders. In contrast, patients with psychotic disorders were more likely to meet the criteria of paranoid (χ² = 11.144, p = 0.001) and schizotypal PD (χ² = 14.004, p < 0.001) diagnoses than those with non-psychotic disorders. Discussion: PD comorbidity is common and comorbidity distribution pattern is varied in patients with psychotic and non-psychotic disorders, implicating the development of specific strategies that could screen and assess PDs in psychiatric clinical practice.

Clinical Features, Neuropsychology and Neuroimaging in Bipolar and Borderline Personality Disorder: A Systematic Review of Cross-Diagnostic Studies

Background: Bipolar Disorder (BD) and Borderline Personality Disorder (BPD) have clinically been evolving as separate disorders, though there is still debate on the nosological valence of both conditions, their interaction in terms of co-morbidity or disorder spectrum and their distinct pathophysiology. Objective: The objective of this review is to summarize evidence regarding clinical features, neuropsychological performance and neuroimaging findings from cross-diagnostic studies comparing BD and BPD, to further caracterize their complex interplay. Methods: Using PubMed, PsycINFO and TripDataBase, we conducted a systematic literature search based on PRISMA guidelines of studies published from January 1980 to September 2019 which directly compared BD and BPD. Results: A total of 28 studies comparing BD and BPD were included: 19 compared clinical features, 6 neuropsychological performance and three neuroimaging abnormalities. Depressive symptoms have an earlier onset in BPD than BD. BD patients present more mixed or manic symptoms, with BD-I differing from BPD in manic phases. BPD patients show more negative attitudes toward others and self, more conflictive interpersonal relationships, and more maladaptive regulation strategies in affective instability with separate pathways. Impulsivity seems more a trait in BPD rather than a state as in BD. Otherwise, BD and BPD overlap in depressive and anxious symptoms, dysphoria, various abnormal temperamental traits, suicidal ideation, and childhood trauma. Both disorders differ and share deficits in neuropsychological and neuroimaging findings. Conclusion: Clinical data provide evidence of overlapping features in both disorders, with most of those shared symptoms being more persistent and intense in BPD. Thus, categorical classifications should be compared to dimensional approaches in transdiagnostic studies investigating BPD features in BD regarding their respective explanatory power for individual trajectories. Systematic Review Registration: The search strategy was pre-registered in PROSPERO: CRD42018100268.